ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (
B) due to decreased blood volume, fever (
C) as a result of dehydration and infection, and poor skin turgor (
D) due to decreased tissue hydration. Bradycardia (
A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
Question 2 of 5
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.
Correct Answer: A, B, C
Rationale: The correct steps for administering a cleansing enema are to warm the enema prior to instillation to prevent discomfort, position the client on the left side with the right leg flexed forward to facilitate the flow of the solution, and lubricate the rectal tube or nozzle to ease insertion. Warming the enema helps relax the colon, the left side position helps the solution flow toward the rectum, and lubrication minimizes discomfort and potential injury. Other choices are incorrect: slowly inserting the rectal tube 2 inches is too shallow, hanging the enema container 24 inches above the client's anus may be too high causing a rapid flow and potential injury.
Question 3 of 5
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
Correct Answer: D
Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.
Question 4 of 5
A nurse is caring for a client who has been sitting in a chair for 3 hours. Which of the following problems is the client at risk for developing?
Correct Answer: C
Rationale: The correct answer is C: Pressure ulcer. Prolonged sitting can lead to decreased blood flow to tissues, causing pressure ulcers. Stasis of secretions (
A) is more related to respiratory issues. Muscle atrophy (
B) is a result of inactivity but not typically seen after only 3 hours. Fecal impaction (
D) is more related to constipation, not prolonged sitting.
Question 5 of 5
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?
Correct Answer: D
Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis, a common complication of prolonged bed rest. Using the incentive spirometer helps the client take deep breaths and improve lung function, thereby maintaining airway patency. Encouraging isometric exercises (choice
A) does not specifically target airway patency. Suctioning every 8 hours (choice
B) is not necessary unless there is a specific indication. Giving low-dose heparin (choice
C) is used to prevent blood clots, not to maintain airway patency.