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 rationale is that nursing assistive personnel can be delegated tasks that involve the physical application of restraints once a decision has been made by the healthcare provider to use them. This is within the scope of their training and does not require clinical judgment. Tasks such as determining the need for restraints (
A), assessing the patient's orientation (
B), and obtaining an order for a restraint (
C) involve clinical judgment and assessment skills, which should be done by a licensed nurse or healthcare provider.
Therefore, option D is the appropriate task to delegate to nursing assistive personnel in this scenario.
Question 2 of 5
During the admission assessment
Correct Answer: B
Rationale: The correct answer is B because orientation is a crucial aspect of assessing a patient's cognitive function, which directly impacts fall risk. If a patient is disoriented, they may struggle to navigate their environment safely, increasing the risk of falls.
Choices A, C, D, and E are incorrect because assessing fall risk goes beyond these factors. Walking 2 miles a day may indicate physical strength, but not necessarily cognitive function. Taking a hypnotic may affect alertness but does not directly relate to orientation. Being widowed may have emotional implications but does not directly affect fall risk assessment.
Question 3 of 5
A patient has an ankle restraint applied. Upon assessment
Correct Answer: A
Rationale: The correct answer is A: the nurse finds the toes a light blue color. This indicates impaired circulation due to the restraint. The nurse should immediately remove the restraint to restore circulation and prevent tissue damage. This action takes priority over other choices as it addresses the urgent issue of compromised circulation. Removing the restraint will allow blood flow to return to the toes, preventing further complications. The other choices are less appropriate as they do not directly address the immediate concern of poor circulation. Placing a blanket or doing a neurologic assessment may delay necessary intervention, taking vital signs may provide valuable information but does not address the urgent issue of compromised circulation.
Question 4 of 5
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
Correct Answer: B,C,E,F
Rationale:
Correct Answer: B, C, E, F
Rationale:
B: Documenting the specific time and type of restraints applied ensures accurate monitoring and compliance with protocols.
C: Noting the presence and quality of radial pulses helps in assessing circulation and preventing complications related to restraints.
E: Documenting unsuccessful attempts to distract the patient with television indicates efforts made to address the patient's needs.
F: Recording any interventions or actions taken is crucial for continuity of care and legal documentation.
Summary:
A: Irrelevant to the patient's care in restraints.
D: Focuses on the equipment used rather than patient assessment.
G: No information provided to evaluate this option.
Question 5 of 5
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: The correct answers are A, B, C, and D. Asking where, when, and what the patient was doing during the fall helps to assess the circumstances leading to the fall and potential risk factors. Inquiring about types of injuries provides insight into the severity of the fall and any complications.
Choice E is incorrect as it focuses on post-fall actions rather than the fall event itself. The other choices, F and G, are not provided in the question and are therefore irrelevant.