ATI RN
ATI Nur 231 Fundamentals Exam Questions
Extract:
Question 1 of 5
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
Correct Answer: A
Rationale: 18: A score of 18 on the Braden Scale indicates that the patient is at low risk for skin breakdown. A score of 18 or above suggests that the implemented interventions have effectively reduced the risk of skin impairment.
Question 2 of 5
A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
Correct Answer: B
Rationale: An older adult client who is confused and has urinary frequency: This client is at the greatest risk for a fall. Confusion can impair judgment and coordination, and urinary frequency can lead to hurried movements to the bathroom, increasing the likelihood of falls.
Question 3 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 4 of 5
A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Wash the area of the puncture thoroughly with soap and water: The first action the nurse should take after a needlestick injury is to immediately wash the area with soap and water. This is crucial for minimizing the risk of infection and exposure to potentially infectious materials.
Question 5 of 5
The nurse is teaching a client who is preparing for surgery. Which teaching about a Jackson-Pratt drain will the nurse include?
Correct Answer: D
Rationale: It provides a way to remove drainage and blood from the surgical wound: This accurately reflects the primary function of the Jackson-Pratt drain. It allows for continuous drainage of excess fluids and blood from the surgical site, helping to prevent complications such as hematomas or seromas and promoting better healing outcomes.