ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Nurses’ Notes
First Clinic Vist:
Cliet arrives to dinc with report of increasing shortness of breath, fatigue. and weakness. States they gt short of breath with minimal activiy.
Cllent s alert and oriented to person, pace, and time. Maoves allextremities well, follows simple commands. Sinus tachycardia, Pulses to lowr extremitis wesk with +2 dependent edema present,
Slightlylabored respirations at rst. Chest with wheezes and crackles n the basas. Reports productive cough, especially during the overnight hours.
Bowel sounds al presen. Abdomen distended. Reports bowel movement this am.
States voiding without dfficulty, lear yellow urine
Teaching provided on nuition therapy and adhering to & ow-sodium diet, monitoring fud intake, and Ifestyle changes for heart fallure. Provided medication teaching following provider's increase in furosemide dosage
Question 1 of 5
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice
A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice
B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice
D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
Extract:
Nurses' Notes O Measure the clents intake and output,
1000; O Transfer the client from wheelchar o bed. Client states, *| am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that painisa"7" 0na 01010 pain L] Colect datasbout the clents pain evel. scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fuids started and infusing in lefc peripheral IV site
Question 2 of 5
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.
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.
Extract:
Nurses' Notes: Day 1
Lactated Ringer'sat 100 mbhr infusing into a 20-guage IV catheter in left hand. IV ressing dry and Intact. IV site without redness or swelling. IV fluld infusing vl [ Place a pressure chessing over the IV site.
(03 Apply heat to the clients left hand.
Day2 [ start.a newIV inthe clent’s eft hand. IV site edematous. Skin surrounding catheter site taut blanched, and cool to touch. IV fluid not nfusing.
Question 3 of 5
A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
Correct Answer: A, B, C
Rationale:
Correct
Answer: A, B, C
Rationale:
A: Stop the IV infusion - The IV site is showing signs of infiltration (edematous, blanched, cool skin, IV fluid not infusing). Stopping the infusion prevents further harm.
B: Place a pressure dressing over the IV site - A pressure dressing helps reduce swelling and prevent further infiltration.
C: Apply heat to the client's left hand - Applying heat can help improve blood flow and absorption of any infiltrated fluids, aiding in the resolution of the issue.
Summary:
D: Starting a new IV in a different site would be premature without addressing the current issue of infiltration.
E, F, G: No other actions are indicated based on the information provided.
Extract:
Nurses’ Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackies heard n left upper lobe and decraased braath sounds at bases bilaterally. 0 Heartate
s
Question 4 of 5
A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, warranting follow-up. An oxygen saturation of 88% is below the normal range, indicating hypoxemia. A heart rate of 98 beats/min is elevated, suggesting increased work of breathing or stress on the cardiovascular system.
Choice C, blood pressure of 130/80 mmHg, falls within the normal range and does not require immediate follow-up.
Choices E, F, and G are not relevant findings in this scenario.
Extract:
Question 5 of 5
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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Order the Items
Source Container
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (
B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (
C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (
D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (
A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.