ATI RN
ATI RN Fundamentals 2019 with NGN - Exam 2 Questions
Question 1 of 5
A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Begin by testing the client while they are wearing glasses. This is the correct action because when assessing visual acuity using a Snellen chart for a client who wears glasses, it is important to first test their vision with the glasses on to determine the effectiveness of the current prescription. This provides a baseline for comparison and helps identify any potential issues with the current eyewear. It also ensures that the client is being assessed under their usual visual conditions.
Positioning the client 3.3 m (10 feet) away from the chart (Option
A) is a standard distance for Snellen chart assessments but not specific to clients wearing glasses. Documenting the largest line the client can read on the chart (Option
B) is not the most appropriate action as it does not consider the impact of glasses on visual acuity. Instructing the client to begin the assessment with both eyes open (Option
C) is a general instruction and does not address the use of glasses.
Question 2 of 5
A nurse is caring for a client with a suspected myocardial infarction. Which of the following actions should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action because in a suspected myocardial infarction, adequate oxygenation is crucial to prevent further damage to the heart muscle. Administering oxygen helps improve oxygen delivery to the heart and tissues, reducing the workload on the heart. Providing a back massage (
B) may be soothing but does not address the immediate need for oxygenation. Encouraging ambulation (
C) can be dangerous as it may increase the workload on the heart. Administering a sedative (
D) can further depress the respiratory system and is not indicated in the acute phase of a myocardial infarction.
Question 3 of 5
A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?
Correct Answer: B
Rationale: The correct answer is B: Crackles in the lungs. Crackles indicate fluid accumulation in the lungs due to fluid overload, leading to pulmonary edema. This is a common sign of fluid overload in clients receiving IV fluids. Fever (
A) is not specific to fluid overload. Bradycardia (
C) is more indicative of fluid volume deficit. Flattened neck veins (
D) are also not indicative of fluid overload.
Question 4 of 5
A nurse is preparing to administer insulin to a client with diabetes mellitus. Which of the following actions should the nurse take to ensure safe administration?
Correct Answer: C
Rationale: The correct answer is C: Verify the insulin type and dose with another nurse. This is important for safety to prevent medication errors. Double-checking with another nurse ensures accuracy and can catch any potential mistakes. Option A is incorrect as shaking the insulin vial vigorously can cause air bubbles, affecting the dose accuracy. Option B is incorrect as a smaller gauge needle, like 25-gauge, is preferred for subcutaneous injections. Option D is incorrect as insulin is typically administered in the abdomen, thigh, or buttocks, not the deltoid muscle.
Question 5 of 5
A nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?
Correct Answer: D
Rationale: The correct answer is D: The client's telephone number. The nurse should use the client's telephone number to confirm their identity because it is a unique and personal piece of information that directly links to the individual receiving the medications. Room number (
A) can change, admitting diagnosis (
B) may not be specific to the individual, and next of kin (
C) is not the client's own identity. Phone number (
D) is a reliable method to verify identity quickly and accurately.