ATI RN
ATI Nurs 100 Fundamental Final Exam Questions
Question 1 of 5
A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?
Correct Answer: A
Rationale: The correct answer is A: Nurse. The nurse is ultimately responsible for administering the incorrect dose of medication as they are the one who actually administered it to the patient. The responsibility of accurately interpreting and administering medication orders falls on the nurse, regardless of any potential confusion in the order. The nurse should have clarified the order with the healthcare provider before administering the medication. The other choices are incorrect because the nurse is the frontline caregiver responsible for patient care in this situation, not the healthcare provider who prescribed the medication, the hospital where the error occurred, or the pharmacist who dispensed the medication.
Question 2 of 5
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
Correct Answer: D
Rationale: The correct answer is D. Scatter rugs in the kitchen pose a safety risk for an older adult with decreased vision due to glaucoma. These rugs can be tripping hazards as they are not securely anchored, leading to falls. Handrails in the bathroom (
B) are beneficial for stability. Using a microwave for cooking (
A) is a safe and convenient option. Placing electrical cords along the walls (
C) is a common practice and not specifically risky.
Question 3 of 5
A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?
Correct Answer: C
Rationale: Subjective data are information provided by the client that cannot be observed or measured. Nausea is a symptom that the client verbally reports, making it subjective. Petechiae, blood pressure, and cyanosis are all objective data that can be observed or measured. Petechiae are small red or purple spots on the skin, blood pressure can be measured using a sphygmomanometer, and cyanosis is a bluish discoloration of the skin due to lack of oxygen.
Therefore, the correct answer is C: Nausea.
Question 4 of 5
A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?
Correct Answer: B
Rationale: The correct answer is B. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mmHg or more, or a drop in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing. In this scenario, the patient's blood pressure drops from 130/60 sitting to 110/60 standing, meeting the criteria for orthostatic hypotension.
A: The drop in blood pressure from sitting to standing is not significant enough to confirm orthostatic hypotension.
C: The drop in blood pressure from sitting to standing is not significant enough to confirm orthostatic hypotension.
D: The blood pressure actually increases upon standing, which does not align with orthostatic hypotension criteria.
Question 5 of 5
The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?
Correct Answer: B
Rationale: The correct answer is B: Presence of blood in the stool. This finding indicates potential bleeding, which could be a sign of a serious issue like gastrointestinal bleeding. The nurse must report this immediately for further evaluation and intervention to prevent complications.
Choices A, C, and D are common with ileostomy patients and may not require immediate action unless accompanied by other concerning symptoms. Continuous output from the stoma is expected, malodorous stool is common due to the nature of the procedure, and liquid consistency of stool is typical for ileostomy output.