ATI RN
ATI Nur 231 Fundamentals Exam Questions
Extract:
Question 1 of 5
Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)
Correct Answer: D,E
Rationale: The correct answer is D and E. For a patient with a Morse Fall Scale score of 30, implementing a fall prevention protocol (
D) is crucial to reduce the risk of falls. This includes assessing the environment, providing mobility aids, and implementing safety measures. Educating the patient on using the call light system (E) empowers them to seek assistance when needed, promoting safety.
Choice A is incorrect as independent ambulation may pose a risk due to the high fall score.
Choice B is inappropriate as sedatives can increase fall risk.
Choice C of using restraints is not recommended due to ethical and legal considerations.
Question 2 of 5
The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?
Correct Answer: A
Rationale: The correct answer is A: A 60 year old patient who is on a mechanical ventilator. Mechanical ventilation increases the risk of healthcare acquired infections due to the invasive nature of the procedure, which can introduce pathogens into the respiratory system. Ventilator-associated pneumonia is a common complication in critically ill patients on ventilators, leading to higher infection rates. Patients on ventilators are also more susceptible to colonization by multidrug-resistant organisms.
Therefore, the nurse would consider this patient at the highest risk for developing healthcare acquired infections compared to the other choices.
Choice B: Being a vegetarian and obese does not directly increase the risk of healthcare acquired infections.
Choice C: Smoking may increase the risk of respiratory infections, but it is not as directly related to healthcare acquired infections as being on a ventilator.
Choice D: Having a normal white blood cell count does not necessarily indicate the risk of healthcare acquired infections.
Question 3 of 5
A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Purulent drainage is noted from the site. This finding indicates an infection at the insertion site. Purulent drainage is a classic symptom of infection, suggesting the presence of pus and bacteria. The other options are incorrect because:
A) A cordlike vein suggests thrombophlebitis, not infection.
C) Numbness is not typically associated with an infection but may indicate nerve damage.
D) Sloughing skin may indicate a pressure injury or allergic reaction, not necessarily infection.
Question 4 of 5
A nurse is presenting to a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because using handrails in the bathroom can provide support and stability, reducing the risk of falls. Residents with mobility issues can benefit from this safety measure.
Choice A increases tripping hazard, choice B lacks support, and choice C increases the risk of slipping.
Question 5 of 5
A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?
Correct Answer: D
Rationale: The correct answer is D: Unstageable. A wound with black eschar covering the base indicates necrotic tissue, making it impossible to determine the depth of the wound. This aligns with the definition of an unstageable wound. Stage 1, 2, and 3 wounds involve visible damage to different layers of the skin, which is not the case here. Thus, they are incorrect choices.