ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is alert and oriented.The client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities are performed once each day.On Day 5, the client’s feet are warm, pedal pulses are 2+ bilaterally, plantar flexion contractures are noted bilaterally, and the left heel has a 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, with skin intact.
Question 1 of 5
Which findings require intervention by the nurse?
Correct Answer: A,B,C
Rationale:
Choice A: Once-daily exercises are insufficient to prevent contractures.
Choice B: Nonblanchable erythema indicates a stage 1 pressure ulcer.
Choice C: Contractures require intervention to prevent disability.
Choice D: Normal pulses do not require intervention.
Extract:
Nurses’ Notes
Client 1: The client is admitted with a new diagnosis of rheumatoid arthritis.
Client 2: The client has a history of hyperlipidemia. Atorvastatin 20 mg PO was administered as prescribed.
Client 3: The client is 1 day postoperative. The client reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous was administered as prescribed.
Client 4: The client is admitted with a new diagnosis of heart failure.
Client 5: The client has a stage 2 pressure injury on the left heel.
Client 6: The client is admitted with a new diagnosis of diabetes mellitus.
Question 2 of 5
A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.Exhibits:Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:
Correct Answer: C
Rationale: Client 3 is 1 day postoperative and reports pain as 8 on a scale of 0 to 10, even after Morphine 5 mg subcutaneous was administered as prescribed. This indicates that the client's pain is not well controlled and could be a sign of complications.
Therefore, immediate assessment is required. This client should be the nurse's highest priority.
Extract:
A nurse is attending to a patient who is experiencing discomfort.
Question 3 of 5
Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient's pain?
Correct Answer: A
Rationale: The quality of pain is a subjective description of what the pain feels like to the patient. The statement 'I feel a dull ache in my stomach' provides a description of the quality of the patient's pain.
Extract:
Question 4 of 5
A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus. This site ensures proper subcutaneous delivery and minimizes complications.
Question 5 of 5
A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The nurse should ensure that two fingers can fit under the sleeves to ensure they are not too tight, which could impede blood flow and cause discomfort or injury.