ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
A nurse in a provider's office is caring for a client.
Exhibit 1
Medical History
Initial visit:
Client reports a sedentary lifestyle.
Client is lactose intolerant and denies taking vitamin supplements.
Client is a nonsmoker.
Client does not drink alcohol.
Question 1 of 5
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)
Correct Answer: B,E,F
Rationale: The correct answer includes Vitamin D level, low activity level, and lactose intolerance. Low Vitamin D levels lead to poor calcium absorption, increasing osteoporosis risk. Inadequate physical activity reduces bone density, contributing to osteoporosis. Lactose intolerance may result in low calcium intake, impacting bone health. Phosphorous level, smoking history, and alcohol use do not directly impact osteoporosis risk.
Extract:
Question 2 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is crucial to prevent any potential bruising or irritation at the injection site. Injecting too close to the umbilicus can lead to discomfort and complications. Option A is incorrect as a smaller gauge needle is recommended for heparin injections to minimize tissue trauma. Option C is incorrect as air bubbles should be removed to prevent air embolism, not specifically related to heparin administration. Option D is incorrect as massaging the injection site can cause bruising and should be avoided.
Question 3 of 5
A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer the client's medications one at a time. This is crucial for a client with dysphagia to prevent choking and aspiration. Providing medications separately ensures proper swallowing and minimizes the risk of medication getting stuck in the throat. Giving medications between meals (
A) may not be appropriate as it does not address the swallowing difficulty during medication administration. Assisting the client into semi-Fowler's position (
B) is generally beneficial for dysphagia but not directly related to medication administration. Encouraging the client to use a straw (
C) may further complicate the swallowing process for someone with dysphagia. Overall, administering medications one at a time is the safest and most effective approach in this situation.
Question 4 of 5
A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Weight. In an anthropometric assessment, weight is a crucial measurement to assess a client's nutritional status, growth patterns, and overall health. Weight can indicate changes in fluid balance, muscle mass, and fat stores. It helps in monitoring progress, setting goals, and evaluating the effectiveness of interventions. The other choices are incorrect because: A - Level of orientation is related to cognitive status, not anthropometric assessment; B - Respiratory rate is a vital sign indicating respiratory function, not part of anthropometric assessment; D - Current pain level is important for pain management but not relevant to anthropometric assessment.
Question 5 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
1. The nurse must assess the client's risk for self-harm or suicide, as the client expressed a desire to die.
2. Asking directly about self-harm opens the conversation and allows the nurse to assess the severity of the client's thoughts.
3. This response shows the nurse's concern for the client's safety and well-being.
4. It initiates a crucial dialogue to determine the appropriate level of intervention needed for the client's safety.
Summary of other choices:
A: Asking about the partner may divert the conversation and miss addressing the immediate risk of self-harm.
C: While discussing feelings with a provider is important, the urgency of the situation requires immediate assessment by the nurse.
D: Inquiring about medication adherence is relevant but not the priority when the client expresses suicidal ideation.