ATI RN
ATI Fundamental Proctored Exam 2024-2025 Online Practice 250 Simulated Exam Questions Questions
Extract:
Question 1 of 5
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
Correct Answer: A
Rationale:
Correct
Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.
Question 2 of 5
A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
Correct Answer: B
Rationale: The correct action is to discontinue the existing IV infusion (
Choice
B) first. The redness, swelling, and warmth at the IV site indicate phlebitis, which is inflammation of the vein. Discontinuing the infusion is crucial to prevent further damage and infection. This step helps to stop the irritant (IV solution) from causing more harm. Inserting an IV catheter in the opposite extremity (
Choice
A) does not address the current issue and may lead to the same problem. Applying warm, moist compresses (
Choice
C) could potentially worsen the inflammation. Elevating the extremity (
Choice
D) may provide some relief, but it does not address the root cause.
Therefore, discontinuing the existing IV infusion is the most appropriate immediate action to take in this situation.
Question 3 of 5
A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?
Correct Answer: C
Rationale: The correct answer is C: Blood. A stool guaiac test is used to detect the presence of occult (hidden) blood in the feces, which may indicate gastrointestinal bleeding. This test helps in diagnosing various gastrointestinal conditions such as ulcers, polyps, or colorectal cancer. Detecting blood in the stool is crucial for early diagnosis and intervention.
Choices A, B, and D are incorrect as stool guaiac test specifically looks for blood, not bacteria, parasites, or fat in the feces. Blood in the stool is a significant finding that requires further investigation, making it the appropriate response in this scenario.
Question 4 of 5
A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Perform the Heimlich maneuver on the guest. This is the appropriate action for a choking individual who is unable to speak or breathe. The Heimlich maneuver helps dislodge the obstruction from the airway by applying abdominal thrusts. It is crucial to act quickly in such situations to prevent further complications like loss of consciousness or asphyxiation.
Choice A is incorrect as mouth-to-mouth resuscitation is not appropriate for a choking victim.
Choice B is incorrect as observing without taking immediate action can be dangerous if the individual's airway is completely blocked.
Choice D is incorrect as slapping the back may not effectively dislodge the obstruction. It is essential to prioritize the Heimlich maneuver to clear the airway and restore breathing.
Question 5 of 5
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
Correct Answer: A
Rationale: The correct answer is A: Erythema. Phlebitis is inflammation of the vein, which commonly presents with redness (erythema) at the site. This is due to the body's response to the irritation caused by the IV catheter. Pallor (choice
B) and coolness (choice
C) are not typical signs of phlebitis, as they suggest decreased blood flow rather than inflammation. Drainage (choice
D) may indicate an infection but is not specific to phlebitis. In summary, erythema is the key indicator of phlebitis due to the inflammatory response in the vein.