ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
The nurse is aware that a common cause of under delegation in client care is:
Correct Answer: C
Rationale: Under-delegation often stems from a nurse’s need for perfectionism and control leading to reluctance to delegate tasks as they fear tasks won’t meet their standards. Over-delegation to assistive personnel is related to excessive delegation not under-delegation. A high degree of trust would facilitate delegation and nurses’ heavy workloads mean they often lack time to do all tasks themselves contradicting the idea of having time as a cause.
Question 2 of 5
The nurse finds a client on bed rest experiencing clear signs of dyspnea. The nurse should assist the client to a:
Correct Answer: D
Rationale: Semi-Fowler’s position (head elevated 30-45 degrees) improves lung expansion and oxygenation in dyspnea by reducing diaphragm pressure. Trendelenberg worsens breathing by increasing abdominal pressure side-lying and supine may not optimize lung function.
Question 3 of 5
In order to minimize discomfort when giving an injection to a client the nurse should:
Correct Answer: A
Rationale: Spreading the skin taut reduces discomfort by minimizing needle puncture sensation and stabilizing the tissue for smoother insertion. Applying heat is not standard holding the syringe still ensures accuracy not comfort and blood return checks are for specific injections not pain reduction.
Question 4 of 5
A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to:
Correct Answer: C,E
Rationale: Hyperkalemia (6.3 mEq/L above normal 3.5-5.0 mEq/L) risks cardiac dysrhythmias and neuromuscular issues requiring immediate assessment for muscle weakness/flaccid paralysis and cardiac monitoring to detect life-threatening arrhythmias. Diluting potassium or encouraging potassium-rich foods worsens hyperkalemia and intake/output monitoring is secondary.
Question 5 of 5
The nurse recognizes that the most appropriate reason to suction a client is that:
Correct Answer: D
Rationale: Suctioning is indicated when the client cannot clear secretions effectively as evidenced by gurgling respirations and inability to cough ensuring airway patency. Routine suctioning every eight hours or hourly without clinical need is inappropriate as it may cause trauma or discomfort. Coughing and swallowing sputum indicates effective airway clearance not requiring suctioning.