ATI RN
ATI N 144 Exam 1 Fundamental Concepts for Nursing Practice Questions
Question 1 of 5
A patient at a long-term care facility makes the following statements regarding management of his constipation. Which statement would require follow-up teaching by the nurse?
Correct Answer: C
Rationale: The correct answer is C because taking a laxative every morning and an enema every night for constipation is not recommended without healthcare provider guidance. Overuse of laxatives can lead to dependency and electrolyte imbalances, while enemas can disrupt the natural bowel function and cause irritation.
Choices A, B, and D are all appropriate and effective strategies for managing constipation. Walking promotes bowel motility, increasing fiber and water intake supports regularity, and recognizing the impact of pain medication is crucial.
Question 2 of 5
A nurse is caring for a client who states,I did not take my medication because my partner forgot to remind me. The nurse should identify that the client is demonstrating which of the following defense mechanisms?
Correct Answer: D
Rationale: The correct answer is D: Rationalization. The client is justifying their behavior of not taking medication by blaming their partner. Rationalization is a defense mechanism where one provides logical-sounding explanations to justify their actions or feelings. In this scenario, the client is rationalizing their non-adherence to medication by shifting the responsibility onto their partner. Identification (
A) involves adopting traits of someone else, denial (
B) is refusing to acknowledge reality, and displacement (
C) is redirecting emotions from the real source to a substitute target.
Question 3 of 5
The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment,the nurse notes crackles shortness of breath and jugular vein distention. Based on this data which complication of IV fluid therapy does the nurse anticipate?
Correct Answer: B
Rationale: The correct answer is B: Fluid volume excess. The signs and symptoms of crackles, shortness of breath, and jugular vein distention indicate fluid overload. The IV rate of 150 mL/hr is likely too high for the older adult, leading to excessive fluid administration. Crackles indicate fluid in the lungs, shortness of breath suggests pulmonary congestion due to fluid accumulation, and jugular vein distention signifies increased venous pressure from fluid overload. Fluid volume deficit (
A) would present with different signs such as hypotension and tachycardia. Speed shock (
C) is a rapid reaction to IV medication, not fluid overload. Pulmonary embolism (
D) would present with chest pain, dyspnea, and tachycardia, not the specific signs seen in this case.
Question 4 of 5
A client has chronic back pain from a work-related injury that occurred 5 years ago. Which patient goal meets the SMART criteria?
Correct Answer: D
Rationale: The correct answer is D. This goal is Specific, Measurable, Achievable, Relevant, and Time-bound. It is specific as it focuses on engaging in desired activities without pain exceeding level 3. It is measurable as it sets a clear pain threshold. It is achievable as it is realistic to manage pain during activities. It is relevant as it addresses the client's primary concern of pain management. It is time-bound as it specifies achieving the goal within one month.
Choice A is not specific or measurable.
Choice B lacks specificity and measurability.
Choice C is vague and not time-bound.
Question 5 of 5
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?
Correct Answer: A
Rationale: The correct answer is A: Assessment. In the nursing process, assessment is the first step where data is collected to identify the patient's health status. In this scenario, the nurse failed to assess the patient's blood pressure before administering the antihypertensive medication. This oversight led to administering the medication without knowing the current blood pressure, resulting in a drop in blood pressure and adverse effects. Planning (
B) involves developing a care plan based on assessment data. Diagnosis (
C) involves identifying the patient's health problems. Evaluation (
D) involves determining the effectiveness of interventions, which comes after implementing the plan. In this case, the initial error was in the assessment phase, as proper assessment could have prevented the complications.