ATI RN
Fundamental Of Nursing Nclex Practice Questions Questions
Question 1 of 5
During a seizure, what is the primary intervention?
Correct Answer: A
Rationale: The primary intervention during a seizure is to protect the patient from injury. This includes moving nearby objects that may harm the patient, cushioning the head, and ensuring a safe environment until the seizure subsides. Inserting an airway is not typically done during a seizure unless the patient's airway is compromised, while elevating the head of the bed is not the priority during an active seizure. Withdrawing all pain medications is not necessary unless there are specific contraindications related to the seizure event.
Question 2 of 5
The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature?
Correct Answer: A
Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely.
Question 3 of 5
A nurse obtained a client's pulse and found the rate to be above normal. The nurse documents this finding as:
Correct Answer: D
Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.
Question 4 of 5
Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?
Correct Answer: C
Rationale: When assisting a client to get up in a chair, it is essential to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving.
Question 5 of 5
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
Correct Answer: D
Rationale: In cases where the oral route is not recommended due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate, and arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.