ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse manager is updating protocols for the use of belt restraints.
Question 1 of 5
Which of the following guidelines should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial to ensure the client's safety and well-being when using restraints. Documenting the client's condition regularly allows the nurse to monitor for any changes or signs of distress promptly. This frequent monitoring helps prevent complications or harm that may arise from the use of restraints.
Explanation for why the other choices are incorrect:
B: Attaching the restraint straps to the side rails of the bed can be dangerous as it may cause entrapment or injury to the client.
C: Using a square knot to secure the restraint is not recommended as it can be difficult to untie quickly in case of an emergency.
D: Ensuring there is at least a 2-inch gap between the restraint and the client's body is incorrect because restraints should be applied securely to prevent the client from slipping out or causing self-harm.
Extract:
A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago.
Question 2 of 5
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is characterized by low blood sugar levels, leading to neuroglycopenic symptoms like confusion. Increased thirst (
B) and frequent urination (
C) are more indicative of hyperglycemia. Flushed skin (
D) is not typically associated with hypoglycemia.
Extract:
A nurse and assistive personnel are assigned a group of clients on the unit.
Question 3 of 5
Which of the following clients should the nurse instruct the AP to report to the nurse?
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 88/52 mmHg is considered hypotensive and requires immediate attention. The nurse should instruct the AP to report this client to the nurse promptly for further assessment and intervention to prevent potential complications such as shock.
Choice A is incorrect because not receiving compression stockings, while important, does not pose an immediate threat to the client's health.
Choice B is incorrect as assisting a client to the restroom is within the scope of the AP's duties and does not require immediate attention from the nurse.
Choice C is incorrect as eating only 50% of a meal does not indicate an urgent issue that needs to be reported to the nurse.
Extract:
Question 4 of 5
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step the nurse should take to manage time effectively because it allows for prioritization and organization of tasks. By setting goals, the nurse can identify essential activities and allocate time accordingly. Delegating tasks to the AP (
A) can come after determining goals. Scheduling daily activities (
C) and developing an hourly time frame for tasks (
D) can be more detailed steps that follow after setting goals. Option E, F, and G are not applicable in this context. In summary, determining goals of the day helps the nurse prioritize, organize, and manage time effectively.
Extract:
A charge nurse is teaching a new staff member about factors that increase a client's risk to become violent.
Question 5 of 5
Which risk factor should the nurse include as the best predictor of future violence?
Correct Answer: A
Rationale: The correct answer is A: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Research shows that individuals with a history of violence are more likely to engage in violent behavior again. This pattern of behavior is often consistent over time. Low self-esteem (
B), substance use disorder (
C), and a history of depression (
D) can contribute to violence but are not as reliable predictors as previous violent behavior. These factors may increase the risk of violence but do not have the same level of predictive value as an individual's history of violent behavior.