ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
Correct Answer: D
Rationale:
Step-by-step rationale for why answer D is correct:
1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.
Summary:
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Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
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Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
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Choice C is incorrect as relying solely on objective data overlooks the
Question 2 of 5
A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
Correct Answer: C
Rationale: The correct answer is C because the client demonstrating understanding of using the PCA infusion device should know to communicate with the nurse if the pain persists after using the device. This indicates the client's awareness of the importance of monitoring pain levels and seeking help if needed.
Choice A does not demonstrate understanding of the device's purpose or functionality.
Choice B shows awareness of the risk of overdose but not necessarily how to use the device correctly.
Choice D is incorrect as the client should be the one responsible for administering the medication through the PCA device.
Question 3 of 5
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (bradypnea), leading to shallow breathing. Orthostatic hypotension is a potential side effect due to vasodilation. Nausea is common with opioid use as they can stimulate the chemoreceptor trigger zone. Urinary incontinence (
A) and diarrhea (
B) are not typically associated with opioid analgesics. So, the nurse should anticipate monitoring for bradypnea, orthostatic hypotension, and nausea as potential adverse effects.
Question 4 of 5
A nurse is assessing a client who takes haloperidol (Haldol) for the treatment of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all.
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. Fine motor tremors, acute dystonias, and uncontrollable restlessness are all extrapyramidal symptoms (EPS) commonly associated with haloperidol use. Fine motor tremors refer to involuntary shaking movements, acute dystonias are sudden muscle contractions causing abnormal postures, and uncontrollable restlessness is known as akathisia. These are classic EPS manifestations caused by dopamine blockade in the basal ganglia. Orthostatic hypotension (
A) is a side effect related to alpha-adrenergic blockade, not EPS. Decreased level of consciousness (
D) is not typically associated with EPS but may indicate overdose or other complications.
Question 5 of 5
A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutynin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all.
Correct Answer: A, B, E
Rationale: The correct choices for managing anticholinergic effects of oxybutynin are A, B, and E. A: Taking frequent sips of water helps combat dry mouth, a common anticholinergic effect. B: Wearing sunglasses when exposed to sunlight helps with sensitivity to light, another anticholinergic effect. E: Urinating prior to taking the medication helps reduce urinary retention, a potential side effect.
Incorrect choices: C: Using a soft toothbrush is not directly related to managing anticholinergic effects. D: Taking the medication with an antacid may interfere with its absorption and is not recommended.