ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by:
Correct Answer: C
Rationale: The correct answer is C: Offering the client a pain scale to measure his pain. This is the best way to assess the intensity of the client's pain objectively. Pain scales provide a standardized way for clients to communicate their pain levels, allowing for more accurate assessment and monitoring. Asking what precipitates the pain (choice
A) focuses on triggers, not intensity. Questioning about the location of pain (choice
B) is important but doesn't directly measure intensity. Using open-ended questions (choice
D) may not provide a quantitative measure of pain.
Question 4 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 5 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.