RN ATI FUNDAMENTALS 2024 EXAM

RN ATI FUNDAMENTALS 2024 EXAM Related

Review RN ATI FUNDAMENTALS 2024 EXAM related questions and content

A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.

  • A. Document the client's vital signs.
  • B. Measure the client's intake and output.
  • C. Transfer the client from wheelchair to bed.
  • D. Insert an NG tube for the client.
Correct Answer: A, B, C

Rationale: Correct Answer: A, B, C

Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) as it involves measuring and recording objective data.
B: Measuring intake and output is a task that can be safely delegated to the AP as it requires basic monitoring skills and doesn't involve complex decision-making.
C: Transferring the client from a wheelchair to bed is a physical task that can be delegated to the AP, as long as proper body mechanics are used to prevent injury.
Summary:
D: Inserting an NG tube is a skilled nursing task that requires specialized training and should not be delegated to an AP.
E: No task provided for this option.
F: No task provided for this option.
G: No task provided for this option.

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A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

  • A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
  • B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
  • C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
  • D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B

Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

  • A. Examine personal values about the issue.
  • B. Tell the parents that this is a necessary procedure.
  • C. Inform the parents that the staff does not require their consent.
  • D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A

Rationale: The correct answer is A: Examine personal values about the issue. The nurse should first reflect on their own values to ensure they can provide care without bias. This allows the nurse to approach the situation with empathy and understanding. Choice B is incorrect because it disregards the parents' beliefs. Choice C is incorrect as parental consent is typically required for medical procedures involving minors. Choice D may not be effective as it may come across as disrespectful to the parents' beliefs.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

  • A. Make sure the client's room has at least six air exchanges per hour.
  • B. Make sure the client wears a mask when outside her room if there is construction in the area.
  • C. Place the client in a private room with negative-pressure airflow.
  • D. Wear an N95 respirator when giving the client direct care.
Correct Answer: A

Rationale: The correct answer is A: Make sure the client's room has at least six air exchanges per hour. This is essential for a protective environment post-allogeneic stem cell transplant to reduce the risk of infection. Increasing air exchanges helps remove airborne pathogens and maintain a clean environment. Option B is incorrect as wearing a mask outside the room is not a part of a protective environment. Option C is incorrect as negative-pressure airflow is typically used for clients with airborne infections, not for stem cell transplant clients. Option D is incorrect as N95 respirators are not routinely required for providing direct care in a protective environment setting.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

  • A. Use the Face Legs Activity Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
  • B. Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm.
  • C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
  • D. Palpate the client's abdomen before auscultating bowel sounds.
Correct Answer: B

Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This is the correct physical assessment technique because proper cuff placement is essential for accurate blood pressure measurement. Placing the cuff around 50% of the arm circumference ensures that the blood pressure reading is not falsely elevated or decreased. Incorrect choices: A: Using the FLACC pain rating scale is relevant for pain assessment, but not a physical assessment technique. C: Obtaining an apical heart rate by auscultating at the third intercostal space left of the sternum is incorrect as the fifth intercostal space at the midclavicular line is the correct location. D: Palpating the client's abdomen before auscultating bowel sounds is incorrect as bowel sounds should be auscultated first to prevent stimulating peristalsis.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

  • A. Pad the client's wrist before applying the restraints.
  • B. Evaluate the client's circulation every 8 hr after application.
  • C. Remove the restraints every 4 hr to evaluate the client's status.
  • D. Secure the restraint ties to the bed's side rails.
Correct Answer: A

Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.

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