ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct action is to choose option C: Remove the device from the room. This is the first step to ensure the safety of the client and prevent any potential hazards associated with the fraying electrical cord. By removing the device from the room, the nurse eliminates the immediate risk of electrical malfunction or injury to the client. Initiating a requisition for a replacement device (option
A) can be done after ensuring the client's safety. Reporting the defect to equipment maintenance staff (option
B) is important but not as urgent as removing the device. Ensuring the device inspection sticker is current (option
D) is not the priority when a safety issue is identified.
Question 2 of 5
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first because tachypnea could indicate a potentially life-threatening condition such as a pulmonary embolism or hypoxia. Assessing this client first ensures prompt detection and intervention for any respiratory compromise. Clients with epidural analgesia and weakness in lower extremities (
A) may need assessment for neurovascular compromise but are not in immediate danger. Clients with sinus arrhythmia (
C) on cardiac monitoring and diabetes mellitus with HbA1C of 6.8% (
D) require monitoring and management but do not present an immediate threat to their health.
Question 3 of 5
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
Correct Answer: A
Rationale: The correct answer is A: Latex. Latex allergies are crucial to address prior to IV therapy as latex is commonly found in medical equipment like gloves and IV tubing. An allergic reaction to latex can be severe and life-threatening. Seafood, bee stings, and peanuts are not typically related to IV therapy and would not directly impact the administration of the therapy. The focus should be on latex allergy due to its direct relevance to medical equipment used during IV therapy.
Question 4 of 5
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct Answer: C - "I should remove constrictive clothing prior to measuring my blood pressure."
Rationale: Removing constrictive clothing ensures accurate blood pressure readings by preventing constriction that may falsely elevate the readings. This statement demonstrates an understanding of the importance of proper preparation for accurate measurements.
Choice A is incorrect because waiting 15 minutes after drinking coffee is not necessary for accurate blood pressure measurement.
Choice B is incorrect because measuring blood pressure with the arm elevated above the heart can lead to inaccurate readings.
Choice D is incorrect because measuring blood pressure immediately after eating can also lead to inaccurate results due to the body's postprandial response.
The correct choice, C, emphasizes the importance of removing constrictive clothing, which is crucial for obtaining accurate blood pressure readings.
Question 5 of 5
A nurse is planning to reposition a client who had a stroke. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Evaluating the client's ability to help with repositioning is crucial for maintaining their independence and preventing complications such as pressure ulcers. It ensures the client's safety and dignity while promoting autonomy in their care. By assessing the client's ability, the nurse can determine the level of assistance needed and tailor the repositioning technique accordingly.
Summary of other choices:
B: Repositioning the client without assistive devices may not be safe or appropriate, especially for a stroke client who may require specific positioning aids for proper alignment.
C: Raising side rails during repositioning is important for safety but does not directly address the client's ability to assist with repositioning.
D: Discussing the client's preferences for a repositioning schedule is important but does not address the immediate need to evaluate their ability to assist with repositioning.