ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
Nurses’ Notes
• The client reports a sudden onset of chest tightness and difficulty breathing starting approximately 30 minutes ago.
• The client is anxious and visibly distressed, clutching her chest intermittently.
• She has a history of hypertension and diabetes, which are being managed with medication.
• On examination, the client is sitting upright and appears to be in moderate respiratory distress.
• The client mentions feeling lightheaded and reports a slight headache.
• She is sweating profusely and her skin is pale.
• The client denies any recent physical exertion or known exposure to irritants.
Vital Signs
• Temperature: 37.2°C (99.0°F)
• Heart Rate: 104 beats per minute
• Respiratory Rate: 22 breaths per minute
• Blood Pressure: 158/92 mmHg
Physical Examination Results
• The client’s lungs exhibit bilateral wheezing and crackles upon auscultation.
• There is no visible swelling or edema in the extremities.
• The client has a dry cough that is intermittent.
• No cyanosis is noted around the lips or extremities.
• The client’s skin is cool and clammy.
• The client appears slightly disoriented when asked questions.
• There is no sign of trauma or injury.
Question 1 of 5
A 45-year-old female client is admitted to the emergency department with complaints of sudden shortness of breath and chest tightness. She has a history of hypertension and diabetes.Exhibits:A nurse is assessing the client at 0700 hrs. Which of the following actions should the nurse take first? A Initiate a cardiac enzyme panel
Correct Answer: D
Rationale: The client's symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart's electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client's symptoms and initiate appropriate treatment.
Extract:
A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is alert and oriented.The client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities are performed once each day.On Day 5, the client’s feet are warm, pedal pulses are 2+ bilaterally, plantar flexion contractures are noted bilaterally, and the left heel has a 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, with skin intact.
Question 2 of 5
Which findings require intervention by the nurse?
Correct Answer: A,B,C
Rationale:
Choice A: Once-daily exercises are insufficient to prevent contractures.
Choice B: Nonblanchable erythema indicates a stage 1 pressure ulcer.
Choice C: Contractures require intervention to prevent disability.
Choice D: Normal pulses do not require intervention.
Extract:
A nurse is preparing to suction secretions from a patient who has a new tracheostomy.
Question 3 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning.
Extract:
Question 4 of 5
Which of the following items should be recorded as 120 mL of fluid in the client's intake and output record?
Correct Answer: C
Rationale: 8 oz of ice chips is approximately equivalent to 120 mL because when ice melts, it reduces in volume by about half, so 8 oz of ice chips would melt to about 4 oz of water, which is approximately 120 mL.
Question 5 of 5
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness, allowing individuals to express their preferences.