ATI RN Fundamentals Practice Assessment| Answered With Rationale| 2023
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ATI RN Fundamentals
ATI RN Fundamentals Practice Assessment| Answered With Rationale| 2023
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
1. Ask another nurse to ...
ati rn fundamentals practice assessment| answered with rationale| 2023 a nurse is preparing to administer an injection of an opioid medication to a client the nurse draws out 1 ml of the medication
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ATI RN Fundamentals Practice Assessment|
Answered With Rationale| 2023
A nurse is preparing to administer an injection of an opioid medication to a client.
The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the
following actions should the nurse take?
1. Ask another nurse to observe the medication wastage
2. Notify the pharmacy when wasting the medication
3. Lock the remaining medication in the controlled substances cabinet
4. Dispose of the vial with the remaining medication in sharps container
1. Ask another nurse to observe the medication wastage
rationale: A second nurse must witness the disposal of any portion of a dose of a
controlled substance
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over
7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round
the answer to the nearest whole number).
107 mL/hr
rationale: 750/7 = 107 mL/hr
A nurse is educating a client who has a terminal illness about declining
resuscitation in a living will. The client asks, "What would happen if I arrived at
the emergency department and I had difficulty breathing?" Which of the following
responses should the nurse make?
1. "We would consult the person appointed by your health care proxy to make
decisions"
2. "We would give you oxygen through a tube in your nose"
3. "You would be unable to change your previous wishes about your care"
4. "We would insert a breathing tube while we evaluate your condition"
2. "We would give you oxygen through a tube in your nose"
rationale: Oxygen can provide comfort and is not considered a resuscitative measure
when the nurse delivers it via nasal cannula.
A nurse is caring for a client who is postoperative and refuses to use an incentive
spirometer following major abdominal surgery. Which of the following actions is
the nurse's priority?
1. Request that a respiratory therapist discuss the technique for incentive
spirometry with the client
2. Determine the reasons why the client is refusing to use the incentive
spirometer
3. document the client's refusal to participate in health restorative activities
4. Administer a pain medication to the client
2. Determine the reasons why the client is refusing to use the incentive spirometer.
rationale: The first action the nurse should take when using the nursing process is to
,assess the client; therefore, the priority action for the nurse to take is to determine why
the client is refusing the treatment
A nurse on a medical-surgical unit is caring for a client for a client who has a new
prescription for wrist restraints. Which of the following actions should the nurse
take?
1. Pad the client's wrist before applying the restraints
2. Evaluate the client's circulation every 8 hours after application
3. Remove the restraints every 4 hours to evaluate the client's status
4. Secure the restraint ties to the bed's side rails
1. Pad the client's wrist before applying the restraints
rationale: The use of restraints without padding can abrade the client's skin, resulting in
client injury
A nurse is talking with an older adult client who is contemplating retirement. The
client states, "I keep thinking about how much I enjoy my job. I'm not sure I want
to retire." Which of the following responses should the nurse make?
1. "You would have so much more time to spend with your family"
2. "You should consider getting a part-time job or doing volunteer work"
3. "Let's talk about how the change in your job status will affect you"
4. "Why wouldn't you want to retire and relax?"
3. "Let's talk about how the change in your job status will affect you"
rationale: This response is therapeutic because the nurse is encouraging the client to
verbalize feelings about the life transition of retirement.
A nurse is caring for a client who has pharyngeal diphtheria. Which of the
following types of transmission precautions should the nurse initiate?
1. Contact
2. Droplet
3. Airborne
4. Protective
2. Droplet
rationale: Droplet precautions are a requirement for clients who have infections that
spread via droplet nuclei that are larger than 5 microns in diameter, including rubella,
meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a
mask when providing care or when within 1 m (3 feet) of the client who has a disorder
requiring droplet precautions
A nurse is caring for a group of clients. Which of the following actions should the
nurse take to prevent the spread of infection?
1. Carry a client's soiled linens out of the room in a mesh linen bag
2. place a client who has TB in a room with negative-pressure airflow
3. Provide disposable plates and utensils for a client who is HIV-positive
4. Dispose of a client's blood-saturated dressing in a trash bag inside a second
trash bag
2. Place a client who has tuberculosis in a room with negative-pressure airflow
, rationale: A client who has TB requires airborne precautions, which include placing the
client in a room that has negative-pressure airflow to reduce the risk of infection
transmission
A nurse is assessing an older adult client's risk for falls. Which of the following
assessments should the nurse use to identify the client's safety needs? (select all
that apply)
pupil clarity, visual fields, and visual acuity
A nurse in a long-term care facility is caring for a client who dies during the
nurse's shift. Identify the sequence in which the nurse should perform the
following steps.
1. Obtain the pronouncement of death from the provider.
2. Remove tubes and indwelling lines.
3. Wash the client's body
4. Ask the client's family members if they would like to view the body
5. Place a name tag on the body.
rationale: The first step is to obtain the death pronouncement from the provider. Next,
the nurse should remove tubes and indwelling lines prior to cleansing the client's body.
After cleansing, the nurse should ask the family members if they wish to view the body.
Finally, the nurse should place a name tag on the body before transfer.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10.
Which of the following statements should the nurse identify as an indication that
the client understands the preoperative teaching she received about pain
management?
1. "I think I should take my pain medication more often, since it is not controlling
my pain"
2. "Breathing faster will help my keep my mind off of the pain"
3. " It might help me to listen to music while I'm lying in bed"
4. "I don't want to walk today because I have some pain"
3. "It might help me listen to music while I'm lying in bed"
rationale: Listening to music is an effective non-pharmacological intervention for the
management of mild pain
A nurse is teaching a client and his family how to care for the client's
tracheostomy at home. Which of the following instructions should the nurse
include in the teaching?
1. Remove the outer cannula cautiously for routine cleaning
2. Use tracheostomy covers when outdoors
3. Use sterile technique when performing tracheostomy care at home
4. Cleanse irritated skin with full-strength hydrogen peroxide
2. Use tracheostomy covers when outdoors.
rationale: Tracheostomy covers protect the client's airway from cold air, dust, and other
airborne particles
A nurse is admitting a client who is having an exacerbation of heart failure. In
planning this client's care, when should the nurse initiate discharge planning?
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