ATI RN
ATI Nurse 142 Final Questions
Question 1 of 5
The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates the pain as a 7 out of 10 (0 is no pain and 10 is the worst pain possible). This client is moving around easily and is eating well, but has asked for pain medication. Which action by the nurse is most appropriate?
Correct Answer: B
Rationale: Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In general, withholding pain medication for a client in pain is not an appropriate action. Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration. It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim.
Question 2 of 5
The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?
Correct Answer: B
Rationale: Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips.
Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.
Question 3 of 5
When assessing the abdomen, the nurse would expect to auscultate which sounds?
Correct Answer: A
Rationale: When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute. Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta. Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs. Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment.
Question 4 of 5
The nurse is performing a nutritional assessment. Which of the following would be considered objective data?
Correct Answer: C
Rationale: Objective data are measurable and observable findings that can be obtained through physical examination, laboratory tests, or other diagnostic procedures. Body Mass Index (BMI) is a calculated value based on height and weight, making it objective. Dietary history, patient complaints, and history of alcohol intake are subjective as they rely on the patient's self-report and may not be entirely accurate.
Question 5 of 5
The nurse is assessing the patient's range of motion. The nurse asks the patient to circumduct his arms. When the patient asks what this means, the nurse explains:
Correct Answer: B
Rationale: Circumduction is a movement that involves the circular rotation of a limb, such as an arm or leg, around a fixed point. When assessing the patient's range of motion, the nurse may ask the patient to perform circumduction of their arms to evaluate their ability to move their arms in a circular motion.