ATI RN
ATI Nur 231 Fundamentals Exam Questions
Extract:
Question 1 of 5
The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?
Correct Answer: A
Rationale: A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation.
Question 2 of 5
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
Correct Answer: B
Rationale: WBC count: An elevated white blood cell (WB
C) count is a classic indicator of infection. The body responds to infection by increasing the production of white blood cells to fight off pathogens. A significantly elevated WBC count, especially if accompanied by a shift to the left (an increase in immature neutrophils), suggests an acute inflammatory response and the presence of an infection, making this the correct answer.
Question 3 of 5
A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Bend at the knees when picking up an object: This instruction is crucial for preventing back strain. Bending at the knees allows the client to use her legs' strength to lift the object rather than putting pressure on the back. This technique helps protect the spine and promotes safe lifting practices.
Question 4 of 5
The nurse is notifying the HCP of the client's change in status using the SBAR format. In which order should the nurse place the statements? 1. 'I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client.' 2. 'The client is deteriorating, and I'm afraid the client is going to arrest.' 3. 'I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C).' 4. 'The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask.'
Correct Answer: A
Rationale: In SBAR format, the order is: Situation (2), Background (4), Assessment (3), and Recommendation (1). This statement provides a clear and urgent indication of the client's current status, emphasizing the severity of the situation and the immediate concern for potential cardiac arrest. The nurse’s choice of language conveys a sense of urgency that is crucial for the HCP to understand the need for prompt action.
Question 5 of 5
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?
Correct Answer: C
Rationale: Footboard: A footboard is the most appropriate device to prevent plantar flexion contractures. It provides support to the feet and helps keep them in a neutral position.