ATI RN CONCEPT-BASED ASSESSMENT
ONLINE PRACTICE ACTUAL EXAM TEST
BANK 100% RELIABLE WITH RATIONALES
A nurse is preparing to administer a unit of packed RBCs to a
client. In adherence with the Joint Commission Nation Patient
Safety Goals regarding blood administration, what actions should
the nurse plan to take?
1. Review the client's medical record for previous transfusion
information.
2. Administer premedication to the client as prescribed by the
provider.
3. Verify the client and blood component using a two-person
process.
4. Educate the client about manifestations to report to the nurse
immediately. -Answer:-Verify the client and blood component
using a two-person process.
Rationale: The Joint Commission National Patient Safety Goals
regarding blood transfusions includes improving the accuracy of
client identification. The nurse should eliminate transfusion
,errors related to client misidentification by using a two-person
verification process to identify the client and the blood
component.
A nurse is creating a plan of care for a client who is
nonambulatory and has bladder and bowel incontinence. What
interventions should the nurse include to prevent skin break
down?
1. Use a sheepskin device to pad the client's pressure points.
2. Apply cornstarch to the perineal area after bathing the client.
3. Massage the client's skin and pressure points every 12 hr.
4. Offer the client a glass of water every 2 hr when repositioning. -
Answer:-Offer the client a glass of water every 2 hr when
repositioning.
Rationale: The nurse should offer the client a glass of water
every 2 hr on the client's repositioning schedule. This helps
prevent dehydration, which increases the risk of skin breakdown.
,A nurse is providing teaching to a client who has chronic fatigue
syndrome. Which of the following statements should the nurse
make? -Answer:-Take NSAIDs for body aches and paim
Rationale: The nurse should instruct the client that NSAIDs can
alleviate the body aches and pain that are associated with chronic
fatigue syndrome. Alternative therapies, such as tai chi and
massage, can also be helpful.
A nurse is administering enoxaparin subcutaneously to a client
who is postoperative and is at risk of thromboembolic events.
What following actions should the nurse take?
1. Insert the needle at a 15º angle after cleansing the site.
2. Pull up a small amount of skin using the thumb and forefinger
of the nondominant hand.
3. Insert about half of the needle length into the tissue.
4. Pull back on the plunger to check for blood return before
administering the medication. -Answer:-Pull up a small amount of
skin using the thumb and forefinger of the nondominant hand.
, Rationale: Pulling up or pinching the skin brings the
subcutaneous tissue upward and helps reduce the pain of the
injection.
A nurse is preparing to administer an immunization via IM
injection into an adult client's deltoid muscle. What actions should
the nurse take?
1. Limit the volume of fluid injected to 3 mL.
2. Aspirate and check for blood prior to injection of the vaccine.
3. Pinch the client's skin with the nondominant hand while
inserting the needle.
4. Select a 1-inch needle for the injection. -Answer:-Select a 1-inch
needle for the injection.
Rationale: The nurse should select a 1-inch needle for an IM
injection into the deltoid muscle. Depending on the client's
weight, the nurse might need to use a 1 ½-inch needle to ensure
injection of the vaccine into the muscle.
ONLINE PRACTICE ACTUAL EXAM TEST
BANK 100% RELIABLE WITH RATIONALES
A nurse is preparing to administer a unit of packed RBCs to a
client. In adherence with the Joint Commission Nation Patient
Safety Goals regarding blood administration, what actions should
the nurse plan to take?
1. Review the client's medical record for previous transfusion
information.
2. Administer premedication to the client as prescribed by the
provider.
3. Verify the client and blood component using a two-person
process.
4. Educate the client about manifestations to report to the nurse
immediately. -Answer:-Verify the client and blood component
using a two-person process.
Rationale: The Joint Commission National Patient Safety Goals
regarding blood transfusions includes improving the accuracy of
client identification. The nurse should eliminate transfusion
,errors related to client misidentification by using a two-person
verification process to identify the client and the blood
component.
A nurse is creating a plan of care for a client who is
nonambulatory and has bladder and bowel incontinence. What
interventions should the nurse include to prevent skin break
down?
1. Use a sheepskin device to pad the client's pressure points.
2. Apply cornstarch to the perineal area after bathing the client.
3. Massage the client's skin and pressure points every 12 hr.
4. Offer the client a glass of water every 2 hr when repositioning. -
Answer:-Offer the client a glass of water every 2 hr when
repositioning.
Rationale: The nurse should offer the client a glass of water
every 2 hr on the client's repositioning schedule. This helps
prevent dehydration, which increases the risk of skin breakdown.
,A nurse is providing teaching to a client who has chronic fatigue
syndrome. Which of the following statements should the nurse
make? -Answer:-Take NSAIDs for body aches and paim
Rationale: The nurse should instruct the client that NSAIDs can
alleviate the body aches and pain that are associated with chronic
fatigue syndrome. Alternative therapies, such as tai chi and
massage, can also be helpful.
A nurse is administering enoxaparin subcutaneously to a client
who is postoperative and is at risk of thromboembolic events.
What following actions should the nurse take?
1. Insert the needle at a 15º angle after cleansing the site.
2. Pull up a small amount of skin using the thumb and forefinger
of the nondominant hand.
3. Insert about half of the needle length into the tissue.
4. Pull back on the plunger to check for blood return before
administering the medication. -Answer:-Pull up a small amount of
skin using the thumb and forefinger of the nondominant hand.
, Rationale: Pulling up or pinching the skin brings the
subcutaneous tissue upward and helps reduce the pain of the
injection.
A nurse is preparing to administer an immunization via IM
injection into an adult client's deltoid muscle. What actions should
the nurse take?
1. Limit the volume of fluid injected to 3 mL.
2. Aspirate and check for blood prior to injection of the vaccine.
3. Pinch the client's skin with the nondominant hand while
inserting the needle.
4. Select a 1-inch needle for the injection. -Answer:-Select a 1-inch
needle for the injection.
Rationale: The nurse should select a 1-inch needle for an IM
injection into the deltoid muscle. Depending on the client's
weight, the nurse might need to use a 1 ½-inch needle to ensure
injection of the vaccine into the muscle.
