ATI RN
ATI Fundamentals Exam East Wick College Questions
Question 1 of 5
A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Weak, irregular pulse. Hypokalemia, low potassium levels, can lead to cardiac dysrhythmias, causing a weak and irregular pulse. Other options are incorrect. A: Hyperactive reflexes are not typically associated with hypokalemia. C: Extreme thirst is more indicative of hypernatremia, high sodium levels. D: Hyperactive bowel sounds are seen in hyperkalemia, high potassium levels.
Question 2 of 5
A nurse is preparing to administer a subcutaneous injection to a client. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Cleanse the injection site with a circular motion. This action is crucial to prevent infection by removing dirt, bacteria, and oils from the skin. Using a circular motion ensures thorough cleansing.
A: Using the dominant hand to pinch the skin is unnecessary for subcutaneous injections and may cause unnecessary discomfort to the client.
B: Donning sterile gloves is not required for subcutaneous injections as long as proper hand hygiene is maintained.
C: Injecting at a 15° angle is incorrect for subcutaneous injections, as it should be administered at a 45° or 90° angle depending on the client's body fat.
In summary, the nurse should prioritize cleansing the injection site to prevent infection.
Question 3 of 5
A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?
Correct Answer: C
Rationale: The correct angle for administering an IM injection into the ventrogluteal muscle is 90°. This angle allows for optimal penetration into the muscle tissue, ensuring effective absorption of the medication. The ventrogluteal muscle is a deep and thick muscle located away from major nerves and blood vessels, making it a safe and suitable site for IM injections. Injecting at a 90° angle helps prevent inadvertent injection into subcutaneous tissue, reducing the risk of injection site reactions. Additionally, using a 90° angle facilitates proper dispersion of the medication within the muscle, promoting absorption and therapeutic effect. The other angles (45°, 75°, 60°) are not ideal for IM injections into the ventrogluteal muscle as they may not allow for adequate penetration or proper dispersion of the medication, potentially leading to suboptimal therapeutic outcomes.
Question 4 of 5
A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: Blood. A guaiac test detects the presence of occult (hidden) blood in the stool, which may indicate gastrointestinal bleeding. Lipids (
A), bacteria (
B), and bile (
D) are not typically detected by a guaiac test. Blood in the stool is a key indicator of various gastrointestinal conditions, making it the appropriate response in this context.
Question 5 of 5
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following information should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: You may experience a small amount of bleeding around the stoma. This is important to include in teaching because it is common for clients with a new colostomy to experience minor bleeding initially due to the healing process. It is crucial for the client to be aware of this to prevent unnecessary alarm.
A: Incorrect. Fecal output may not occur within 24 hours as the digestive system needs time to adjust to the new changes.
C: Incorrect. A purplish color of the stoma is not a normal finding and should be reported to the healthcare provider.
D: Incorrect. Increasing dietary intake of raw vegetables may cause gas and odor issues for the client with a new colostomy.
In summary, option B is correct because it addresses a common occurrence and helps the client understand what to expect post colostomy surgery.