ATI RN
ATI Fundamental Proctored Exam Study Guide 2024-2025 Questions
Extract:
Question 1 of 5
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The nurse can delegate this task to a nursing assistive personnel because it involves carrying out a physical action based on a clear order from a healthcare provider. The nurse must assess the need for restraints (choice
A), assess the patient's orientation (choice
B), and obtain an order for restraints (choice
C) as these tasks require critical thinking and clinical judgment, which are beyond the scope of practice for a nursing assistive personnel. The nursing assistive personnel can assist with applying the restraint under the direct supervision and guidance of the nurse.
Question 2 of 5
A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes. The priority nursing diagnosis in this scenario is addressing the patient's safety. By checking on the patient every 15 minutes, the nurse can monitor for any attempts to remove the oxygen cannula or urinary catheter, reducing the risk of injury. This intervention allows for timely detection and prevention of harm to the patient.
Choice B: Risk for suffocation: Placing an 'Oxygen in Use' sign on the door does not directly address the immediate safety concern of the patient attempting to remove the oxygen cannula.
Choice C: Disturbed body image: While addressing body image concerns is important, it is not the priority in this situation where the patient's immediate safety is at risk.
Choice D: Deficient knowledge: Explaining the purpose of oxygen therapy and the urinary catheter is important for patient education but does not address the urgent need to prevent injury in this case.
Question 3 of 5
The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services?
Correct Answer: A
Rationale: The correct answer is A. The priority concern requiring collaboration with social services is the electricity being turned off 3 days ago. This situation poses a significant risk to the patient's health and safety, as it may affect the ability to refrigerate food and medications, maintain a comfortable temperature, and operate medical equipment if needed. Collaborating with social services can help address this urgent issue and ensure the patient's well-being.
Choices B, C, and D are incorrect as they do not directly impact the patient's immediate health and safety needs in the same way as the lack of electricity.
Question 4 of 5
A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This finding indicates a drop in blood pressure upon standing, increasing the risk of falls. Orthostatic hypotension can cause dizziness and lightheadedness when changing positions, leading to falls.
Choice A (55 years old) is not a significant risk factor for falls compared to orthostatic hypotension.
Choice B (20/20 vision) does not directly correlate with fall risk.
Choice C (urinary continence) is not a direct indicator of fall risk. In summary, orthostatic hypotension is the most concerning finding as it directly affects the patient's blood pressure regulation and increases the likelihood of falls.
Question 5 of 5
The nurse is performing the 'Timed Get Up and Go (TUG)' assessment. Which actions will the nurse take? (Select all that apply.)
Correct Answer: C,D,F
Rationale:
Correct Answer: C, D, F
Rationale:
C: Instructing the patient to walk 10 feet quickly and safely is a key step in the TUG assessment to evaluate mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is crucial in assessing balance and fall risk during the TUG assessment.
F: Beginning the timing of the assessment after giving instructions ensures an accurate measurement of the patient's performance.
Incorrect
Choices:
A: Ranks a patient as high risk for falls after taking 18 seconds is not a standard criterion for the TUG assessment.
B: Teaching the patient to rise using arms for support is not specific to the TUG assessment and may not be relevant to evaluating mobility and fall risk.
E: Beginning counting after instructions can introduce variability in timing and may not provide an accurate assessment of the patient's performance.