ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 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 2 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 3 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 4 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 5 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.