ATI RN FUNDAMENTALS 2023 EXAM 2 Updated 2024
Total Questions : 62
Showing 25 questions, Sign in for moreA nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Explanation
A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.
B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Explanation
A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.
C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)
Explanation
A. Using grab bars enhances safety while bathing.
B. Having a fire escape plan contributes to home safety.
C. Checking medication expiration dates ensures safe and effective use.
D. Setting the water heater to 140 degrees Fahrenheit may pose a scalding risk.
E. Applying tape to electrical cords is not a safe practice and does not indicate an understanding of safety precautions.
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "I want to die now that my partner is gone." Which of the following responses should the nurse make?
Explanation
A. Advising to discuss with the provider doesn't address the immediate concern of potential harm.
B. Asking about thoughts of self-harm assesses the client's immediate safety.
C. Inquiring about medication discontinuation is important but not as urgent as addressing suicidal ideation.
D. While understanding the relationship is important, it's not the priority when a client expresses suicidal thoughts.
A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. Regular ankle and knee exercises help prevent muscle atrophy due to immobility.
B. Changing positions every 4 hours is helpful, but more frequent movement is recommended.
C. Antiembolic stockings should be worn when immobile to prevent blood clots.
D. Holding breath during movement doesn't contribute to reducing adverse effects of immobility.
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Explanation
A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "I want to die now that my partner is gone." Which of the following responses should the nurse make?
Explanation
A. Advising to discuss with the provider doesn't address the immediate concern of potential harm.
B. Asking about thoughts of self-harm assesses the client's immediate safety.
C. Inquiring about medication discontinuation is important but not as urgent as addressing suicidal ideation.
D. While understanding the relationship is important, it's not the priority when a client expresses suicidal thoughts.
A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)
Explanation
A. Comparing at the end of the shift might lead to missing administration discrepancies during the shift.
B. Comparing the medication label with the administration record is essential when removing the medication to ensure accuracy.
C. Checking immediately before administering ensures the right drug, dosage, and patient match.
D. Reconciling counts of controlled substances ensures accountability and accuracy.
E. Comparing during medication dosage preparation is important but may not catch last-minute changes or discrepancies.
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Explanation
A. Rather than rubbing dry, patting the peristomal skin dry after cleaning is recommended.
B. The frequency of changing the pouch depends on various factors, not a fixed 24-hour schedule.
C. Ensuring the pouch is slightly larger than the stoma prevents irritation and damage.
D. Applying the pouch when the skin barrier is dry ensures better adhesion.
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
Explanation
A. Turning the client onto their side helps prevent aspiration and ensures a clear airway but since the client is seated on a chair, they run the risk of getting a fall hence lying them down is the priority.
B. If a client has a seizure when seated, it is best to ensure their safety by lying them on the floor and moving any objects that can cuase injury.
C. Loosening clothing is important but not the priority over ensuring a clear airway.
D. Moving items away from the client is important to prevent injury, but ensuring airway safety comes first.
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Explanation
A. The gauge and needle length can vary but are typically smaller, such as 25 gauge, for heparin injections.
B. Massaging the site after withdrawing the needle isn't recommended, as it can cause irritation or bleeding.
C. The injection site for heparin is often recommended at least 5 cm (2 inches) away from the umbilicus, but specific sites may vary based on individual instructions.
A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
Explanation
A. Area rugs on tile floors can be a tripping hazard and should be secured or removed.
B. Grabbing bars in the shower promotes safety and stability, so this doesn't require intervention.
C. Prescriptions stored in a medication organizer indicate good medication management and aren't a safety concern.
D. Setting the hot water heater to 47°C (117°F) poses a scalding risk, especially for an older adult with fragile skin due to osteoporosis.
A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?
Explanation
A. Assisting the client into a semi-Fowler's position might be beneficial but doesn't directly address dysphagia while taking medications.
B. Timing medications between meals isn't directly related to improving medication intake for someone with dysphagia.
C. Using a straw might not be recommended as it could increase the risk of aspiration.
D. Administering medications one at a time allows for better control and observation of swallowing ability and reduces the risk of aspiration.
A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should request a referral to which of the following members of the interdisciplinary team?
Explanation
A. Speech-language pathologists specialize in assessing and managing swallowing difficulties (dysphagia) after a stroke.
B. Social workers primarily address psychosocial aspects and may not directly manage swallowing difficulties.
C. Physical therapists focus more on mobility and physical rehabilitation.
D. Occupational therapists help with daily living activities but might not specialize in dysphagia management.
A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
Explanation
A. Area rugs on tile floors can be a tripping hazard and should be secured or removed.
B. Grab bars in the shower promote safety and stability, so this doesn't require intervention.
C. Prescriptions stored in a medication organizer indicate good medication management and aren't a safety concern.
D. Setting the hot water heater to 47°C (117°F) poses a scalding risk, especially for an older adult with fragile skin due to osteoporosis.
A newly licensed nurse has forgotten their password and asks another nurse to access the computer system for them so they can document care before transferring the client to another unit. Which of the following responses should the nurse make?
Explanation
A. Involving the supervisor for a temporary password might not be necessary when other options for password recovery are available.
B. Asking another nurse to document on behalf of the newly licensed nurse might lead to issues related to accountability and accuracy.
C. Providing contact information for password recovery assistance is the most appropriate action.
D. Sharing passwords compromises security and violates policies and should be avoided.
A nurse is preparing to provide postmortem care for a client. Which of the following actions should the nurse plan to take?
Explanation
A. Turning overhead lights to a bright setting may not be appropriate as it can be discomforting for the family and doesn't align with providing respectful postmortem care.
B. Inviting the family to assist in washing the client's body can be a part of therapeutic postmortem care and can help the family members in their grieving process.
C. Removing dentures for the family to keep isn't typically part of postmortem care.
D. Leaving the client's eyes open until the family views the body may not be culturally appropriate and can be distressing for the family.
A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?
Explanation
A. Maintaining a lean body mass can be beneficial but may not directly prevent osteoporosis.
B. Weight-bearing exercises, such as walking, are known to help maintain bone density and prevent osteoporosis.
C. While vitamin B12 is essential for health, it's not specifically linked to osteoporosis prevention.
D. Water aerobics are good for overall fitness but might not have the same impact on bone health as weight-bearing exercises.
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
Explanation
A. Aspiration risk due to frequent coughing while eating is the priority as it can lead to aspiration pneumonia.
B. Blood pressure elevation may need attention but is secondary to the immediate risk of aspiration.
C. Nutritional intake is important, but immediate safety concerns like the risk of aspiration take precedence.
D. Leaning to the left side while sitting might indicate a motor deficit but doesn't present an immediate risk compared to aspiration.
A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?
Explanation
A. Priming the IV tubing with lactated Ringer's isn't necessary for administering packed RBCs.
B. Confirming the client's identity with the blood bank technician is crucial but typically done before receiving the blood product.
C. Ensuring the client has a suitable IV catheter is important but isn't the priority before starting the infusion of packed RBCs.
D. Checking the blood product's compatibility with the client's blood type is critical to prevent adverse reactions before starting the infusion.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Explanation
A. Using a straw can increase the risk of aspiration for someone with dysphagia by bypassing the proper oral control needed for swallowing safely.
B. Adjusting the head of the bed to 90° is an appropriate position for someone with dysphagia during meals, promoting safer swallowing.
C. Taking frequent breaks while eating allows for safe swallowing and prevents fatigue.
D. Tucking the chin when swallowing is a proper technique for aiding safe swallowing for someone with dysphagia.
A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?
Explanation
A. Proceeding with surgery without proper consent can pose legal and ethical concerns.
B. Contacting the ethics committee is essential to get guidance on how to proceed ethically and legally in the absence of consent.
C. Waiting for a family member might delay necessary treatment and could put the client's health at risk.
D. Consent from the surgeon isn't appropriate in this situation as it requires consent from a legal guardian or family member unless in an emergency where immediate action is necessary to save a life and there's no time to obtain consent.
A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
Explanation
A. Expressing a desire for independence indicates the client may not have fully adapted to relying on others yet.
B. Reluctance to ask for help suggests the client is still adjusting and may not have fully embraced the new living arrangement.
C. Expressing enjoyment or appreciation for others cooking for them indicates acceptance of assistance and adaptation to the new living situation.
D. Expressing uncertainty about daily activities suggests a lack of adjustment to the new environment and situation.
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. Avoiding exposure to the sun might decrease vitamin D synthesis, which is necessary for calcium absorption.
B. Decreasing intake of dairy products may decrease calcium intake, which could increase the risk of osteoporosis.
C. Regular weight-bearing exercises like walking help maintain bone density and reduce the risk of osteoporosis.
D. A daily calcium intake of 250 milligrams might be insufficient for osteoporosis prevention; the recommended daily intake varies based on age and gender.
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Explanation
A. Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B. Administering oxygen helps address hypoxia and supports adequate oxygenation.
C. Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D. Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E. Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.
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