ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter.
Question 1 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:
A nurse is planning a teaching session for a group of adolescents who each recently had an ostomy surgically placed.
Question 2 of 5
Which of the following methods should the nurse use as a psychomotor approach to learning?
Correct Answer: D
Rationale: The correct answer is D: Role play. Role play is a psychomotor approach to learning because it involves physical movement and practice of real-life scenarios, enhancing hands-on skills and muscle memory. It allows learners to actively participate, engage in problem-solving, and apply theoretical knowledge to practical situations. Group discussions (
A) focus on cognitive learning through dialogue. Query answer meetings (
B) involve verbal exchanges rather than physical actions. Practice sessions (
C) may involve repetition but lack the interactive and immersive nature of role play.
Extract:
A nurse is preparing to suction secretions from a patient who has a new tracheostomy.
Question 3 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Select a suction catheter that is half the size of the lumen. This is because using a suction catheter that is half the size of the lumen allows for optimal suctioning efficiency without causing trauma to the patient's airway. A suction catheter that is too large can lead to tissue damage and ineffective suctioning.
Choice A is incorrect because using a resuscitation bag with 80% oxygen prior to the procedure is not related to proper suctioning technique.
Choice C is incorrect because placing the end of the suction catheter in water-soluble lubricant is not necessary and can introduce potential infection risks.
Choice D is incorrect because adjusting the wall suction apparatus to a pressure of 170 mm Hg is too high and can cause harm to the patient's airway.
Overall, selecting the appropriate size suction catheter is crucial for effective and safe suctioning procedures.
Extract:
A nurse is caring for a patient who has dementia
Question 4 of 5
What intervention should the nurse take to minimize the risk of injury to the patient?
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention helps to prevent patient falls by alerting the nurse when the patient attempts to leave the bed unsafely. It promotes early intervention and reduces the risk of injury. Raising four side rails (
B) may restrict the patient's movement excessively and could lead to entrapment. Applying a soft wrist restraint (
C) may cause discomfort and compromise the patient's circulation. Dimming the lights (
D) does not directly address the risk of injury.
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 5 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.