ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation.
Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation.
Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice
D) may promote comfort but does not directly reduce thrombus risk.
Question 3 of 5
A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching?
Correct Answer: B
Rationale: The correct answer is B: "This thing will keep the blood pumping through my leg." This statement shows understanding because sequential compression devices help prevent blood clots by promoting blood circulation in the legs. Option A is incorrect as the device does not prevent skin sores. Option C is incorrect as it doesn't specifically address blood circulation. Option D is incorrect as the device does not impact joint health.
Question 4 of 5
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
Correct Answer: A, B, D
Rationale:
Correct
Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
Question 5 of 5
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. By asking about nausea and vomiting, the nurse is assessing for other symptoms that may accompany the abdominal pain, providing crucial information for a comprehensive assessment. This helps in identifying potential causes, such as gastrointestinal issues. Other choices are incorrect because B: Location of the pain, C: Pain quality, and D: Aggravating & relieving factors focus solely on the characteristics of pain itself and not on associated symptoms.