ATI RN
ATI Fundamentals Quiz Questions
Question 1 of 5
A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is placed on the mastoid bone behind the ear and then moved close to the ear canal. If the client can hear the sound better through air conduction than bone conduction, it indicates normal hearing.
Choice A is incorrect as electrodes are not used in the Rinne test.
Choice B is incorrect as earphones are not involved in this test.
Choice D is incorrect as a probe is not inserted inside the ear for the Rinne test.
Question 2 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?
Correct Answer: A
Rationale:
Correct
Answer: A - Secure new tracheostomy ties before removing old ones.
Rationale: By securing new tracheostomy ties before removing old ones, the nurse ensures that the tracheostomy tube remains in place and prevents accidental dislodgment. This step is crucial to maintain the client's airway patency and prevent complications.
Summary of other choices:
B: Using aseptic technique is important in tracheostomy care, but it is not directly related to securing tracheostomy ties.
C: Applying suction when inserting the catheter is incorrect as it increases the risk of trauma and should not be done during routine tracheostomy care.
D: Cleaning the inner cannula with mild soap and water is a part of tracheostomy care, but it is not directly related to securing tracheostomy ties.
Question 3 of 5
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Flush the NG feeding tube with 30 mL of water immediately following medication administration. Flushing the tube with water helps ensure that the medications are completely delivered into the stomach and do not get stuck in the tube. This action also helps prevent clogging of the tube and ensures proper absorption of the medications.
Choice A is incorrect because diluting medications with tap water can alter their effectiveness and lead to inaccurate dosing.
Choice C is incorrect because maintaining the head of the bed flat for 30 minutes following medication administration is not necessary for NG feeding tube care.
It's important for the nurse to prioritize flushing the tube with water to ensure proper medication delivery and prevent complications.
Extract:
Physical Examination
0900:
Client admitted with report of chest pain radiating to the left arm,
sweating, shortness of breath, and epigastric discomfort.
Client awake, alert, and oriented x3.
Lung sounds clear bilaterally, 5152 heart sounds noted.
All pulses palpable.
Skin cool and diaphoretic to touch.
Rates pain as 6 on a 0 to 10 pain scale.
Pain described as sharp in the chest area with feelings of tightness and indigestion.
Bowel sounds active in all 4 quadrants.
Diagnostic Results
0905:
ECG Sinus Tachycardia with ST elevation
Blood glucose 84 mg/dL (74 to 106 mg/dl)
WBC 9,000/mm3 (5,000 to 10,000 mm2)
Platelets 275,000/mm2 (150,000 to 400,000/mm3)
Troponin I 0.7 ng/mL (less than 0.1 ng/mL)
Troponin 10.09 ng/mL (less than 0.03 ng/mL)
Medical History
Hypertension
1 pack per day nicotine use- smoker
Coronary artery disease
Obesity
Erectile dysfunction
Nurses Notes
0915:
18 gauge IV inserted right forearm infusing 0.9% Normal Saline 100 mL/hr. Continuous 12-lead ECG monitoring indicating sinus tachycardia with ST elevation. Provider notified.
Medication Administration Record
Sildenafil 50 mg PO once daily
Simvastatin 40 mg PO once daily
Metoprolol 100 mg PO once daily
Multivitamin once daily
Question 4 of 5
A nurse in the emergency department is caring for client who is experiencing chest pain. Exhibits :The nurse is reviewing the client’s assessment data to prepare the plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Action to Take: Administer Oxygen via nasal canula 2 L/min., Administer transdermal nitroglycerin; Potential Condition: Myocardial Infarction; Parameter to Monitor: Vital signs, Electrocardiogram (ECG) rhythm. Myocardial infarction is the most likely condition due to chest pain. Administering oxygen and nitroglycerin help improve oxygenation and reduce chest pain. Monitoring vital signs and ECG rhythm helps assess the client's cardiovascular status. The other choices are incorrect: Verapamil, aspirin, and morphine are not first-line treatments for myocardial infarction. Ischemic stroke, cardiogenic shock, and chronic stable angina are not the most likely conditions for chest pain. Monitoring serum glucose, WBC count, and platelet count are not specific to assessing myocardial infarction.
Extract:
Nurses' Notes
Client admitted to the emergency department with palpitations, fatigue, weakness, and nocturia.
Client reports awakening 2 to 3 times each night to urinate.
Breath sounds scattered crackles heard bilaterally.
Client reports a dry, hacking cough, especially at night.
Apical heart rate rapid and irregular. Audible 5, gallop.
Color pale, skin cool and clammy to touch.
Vital Signs
Temperature 38.6° C (101.5° F)
Blood pressure 98/50 mm Hg
Pulse rate 112/min
Respiratory rate 28/min
Oxygen saturation 88% on room air
Diagnostic Results
B-type natriuretic peptide (BPN) 410 pg/mL (less than 100 pg/mL) Electrocardiogram: Atrial fibrillation
Question 5 of 5
A nurse in the emergency department is caring for a client. Exhibit 1: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Action to Take: Administer supplemental oxygen, Prepare to administer bronchodilator; Potential Condition: Asthma; Parameter to Monitor: Pulmonary function tests, Neurological Status.
Rationale:
1. Administering supplemental oxygen and preparing to administer a bronchodilator are appropriate actions for managing an asthma exacerbation.
2. Asthma is the most likely condition based on the symptoms described (wheezing, shortness of breath).
3. Monitoring pulmonary function tests can assess the client's lung function, and monitoring neurological status can help detect any complications or changes in mental status.
4. The other choices (Pulmonary embolism, Dehydration, Left-sided heart failure) do not align with the given symptoms and actions, making them incorrect options.