ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention?
Correct Answer: C
Rationale: The correct answer is C: "I don't even know who I am yet, & now I'm supposed to know what to do." This statement highlights an existential crisis and identity confusion, which are common developmental challenges in young adulthood. It indicates a lack of self-awareness and direction, which can significantly impact the individual's overall well-being and decision-making capabilities. Addressing this issue is crucial as it forms the foundation for addressing other concerns effectively.
Choices A, B, and D focus on external stressors and specific situations, which are important but secondary to the core issue of self-identity.
Therefore, prioritizing assessment and intervention for the client's self-identity crisis is essential to promote holistic growth and resolution of other challenges.
Question 2 of 5
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all.
Correct Answer: B, C, D
Rationale: The correct recommendations for young adults are B, C, and D. Young adults are more likely to engage in activities like skiing that pose a risk of head injuries, hence wearing a helmet (
B) is crucial. Carbon monoxide poisoning can occur from faulty heating systems or appliances, making it important to install a detector (
C). Additionally, young adults may be more likely to own firearms, so securing them in a safe location (
D) is essential to prevent accidents. Installing bath rails (
A) and removing throw rugs (E) are more relevant to older adults to prevent falls.
Question 3 of 5
A nurse is reviewing the CDC's immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all.
Correct Answer: A, B, C
Rationale: The correct answer includes Human papillomavirus (HPV), Measles, mumps, rubella (MMR), and Varicella vaccines. These vaccines are recommended by the CDC for young adults to prevent serious diseases. HPV vaccine helps prevent certain types of cancers, MMR protects against highly contagious viral infections, and Varicella prevents chickenpox. The incorrect choices, Haemophilus influenzae type b (Hib) and Polio, are typically given during infancy and are not part of routine vaccinations for young adults. In summary, the correct recommendations focus on preventing common infections in this age group, while the incorrect choices are either not relevant or administered at a different life stage.
Question 4 of 5
A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
Correct Answer: A, C, E
Rationale:
Correct
Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.
Incorrect
Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.
Question 5 of 5
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
Correct Answer: A
Rationale:
Correct
Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa.
Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.