ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.
On Day 1, Lactated Ringer’s was infusing at 100 mL/hr into a 20-gauge IV catheter in the left hand. The IV dressing was dry and intact.
The IV site was without redness or swelling. The IV fluid was infusing well.
On Day 2, the IV site was edematous.
The skin surrounding the catheter site was taut, blanched, and cool to touch. The IV fluid was not infusing.
The nurse is assessing the client.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: A,B,C
Rationale: The correct actions for the nurse to take are A, B, and C. A: Stopping the IV infusion is necessary if there are signs of infiltration or phlebitis. B: Elevating the client's left arm helps reduce swelling and promote venous return. C: Applying heat to the client's left hand can improve circulation and comfort.
Choice D is incorrect as starting a new IV without addressing the current issue is unnecessary.
Choices E, F, and G are not provided, but based on the rationale, they would also be incorrect since the correct actions address the current problem effectively.
Extract:
Question 2 of 5
A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)
Correct Answer: B,C,D
Rationale: The correct assessments for identifying an older adult client's safety needs are appearance of gait, visual fields, and visual acuity. Gait appearance helps determine balance and coordination, crucial for fall risk. Visual fields are important for detecting peripheral vision deficits that can contribute to falls. Visual acuity assesses the client's ability to see clearly, which is essential for navigating obstacles and hazards. Pupil clarity (choice
A) is not directly related to fall risk assessment. The other choices (E, F, G) are not provided, so they cannot be evaluated.
Extract:
A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter.
Question 3 of 5
Which of the following observations at the IV site should the nurse identify as signs of infiltration?
Correct Answer: A
Rationale: The correct answer is A: Skin blanching. Blanching occurs when the blood flow is compromised due to infiltration, causing the skin to appear pale or white when pressure is applied. This indicates that the IV fluid is not entering the vein properly and is leaking into the surrounding tissues. Bleeding (choice
B) is not a typical sign of infiltration but rather indicates a puncture site issue. Purulent exudate (choice
C) suggests infection, not infiltration. Warmth (choice
D) is more indicative of phlebitis, inflammation of the vein. Other choices are not relevant to infiltration assessment. In conclusion, skin blanching is the key indicator of infiltration due to compromised blood flow, distinguishing it from other complications.
Extract:
Question 4 of 5
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously.Determine the correct order of steps for this procedure.
Correct Answer: C,A,D,B
Rationale:
Correct Answer: C, A, D, B
Rationale:
1. Injecting air into the bottle of NPH insulin (
C) prevents a vacuum from forming when you withdraw the dose.
2. Injecting air into the bottle of regular insulin (
A) prevents negative pressure, making it easier to withdraw the dose.
3. Withdraw the correct dose of regular insulin (
D) first to avoid contamination.
4. Withdraw the correct dose of NPH insulin (
B) last as it is a longer-acting insulin, ensuring proper mixing and administration.
Summary:
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Choice A is incorrect as air should be injected into the NPH insulin bottle first.
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Choice B is incorrect as NPH insulin should be drawn last.
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Choice D is incorrect as regular insulin should be drawn before NPH insulin.
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Choice E, F, and G are not relevant to the correct order of steps.
Question 5 of 5
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. This is accurate as advance directives are legal documents that allow individuals to communicate their wishes regarding medical treatment in advance, ensuring their preferences are known and followed in case they are unable to communicate.
Choice A is incorrect as advance directives do not allow the court to overrule a client's refusal of medical treatment.
Choice C is incorrect as advance directives do not permit withholding medical information.
Choice D is incorrect as advance directives do not dictate what health care personnel can do in an emergency.