ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Report observations to the nurse manager on the unit. This action is crucial for patient safety and the well-being of the drowsy nurse. By reporting to the nurse manager, appropriate steps can be taken to address the issue, such as evaluating the nurse's workload, offering support or counseling, or implementing policies to prevent such incidents in the future.
Choice A is incorrect as simply reminding the nurse may not address the underlying issue.
Choice B is less effective as it may delay necessary intervention.
Choice D is incorrect as patient safety is a collective responsibility. Reporting to the nurse manager is the best course of action to ensure proper handling of the situation.
Question 2 of 5
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, C. A postop wound infection typically presents with increased incisional pain (
A), fever & chills (
B), and reddened wound edges (
C). Pain may be due to inflammation caused by the infection. Fever and chills are systemic signs of infection. Reddened wound edges indicate inflammation and possible infection spreading.
Choices D and E are incorrect as increased serosanguineous drainage (
D) may be seen in the normal healing process, and a decrease in thirst (E) is not typically associated with wound infection.
Question 3 of 5
A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer?
Correct Answer: 0.3
Rationale:
Correct Answer: 0.3 mL
Rationale:
To calculate the mL to administer, divide the dose needed (10 mg) by the concentration available (40 mg/mL). 10 mg / 40 mg/mL = 0.25 mL. Since the available concentration is rounded to the nearest tenth (0.3 mL), this is the amount the nurse should administer.
Summary of other choices:
A: Incorrect, as it does not follow the correct calculation process.
B: Incorrect, as it does not consider the concentration of the medication.
C: Incorrect, as it does not involve the necessary division calculation.
D: Incorrect, as it does not relate the dose needed to the concentration available.
E: Incorrect, as it does not provide a logical explanation for the calculation.
F: Incorrect, as it lacks the step-by-step calculation process.
G: Incorrect, as it does not explain how to determine the mL to administer.
Question 4 of 5
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
Correct Answer: A, B, C
Rationale: The correct answer includes guidelines A, B, and C. Placing the client in semi-Fowler's position allows for easier chest expansion. Having the client rest an arm across the abdomen helps to promote relaxation and allows for easier observation of respiratory movements. Observing one full respiratory cycle before counting the rate ensures an accurate assessment. Guidelines D and E are incorrect. Counting the rate for one minute is unnecessary if the rate is regular; it can be counted for 30 seconds and then doubled. Reporting sighs is not a standard practice in measuring respiratory rate and is not relevant to the assessment.
Question 5 of 5
A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
Correct Answer: D
Rationale:
Correct Answer: D (Illness)
Rationale:
1. The client is experiencing symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes, indicating an active infection.
2. The illness stage is characterized by the manifestation of specific symptoms as the body tries to fight off the infection.
3. During the illness stage, the infection is fully developed and the individual exhibits overt signs and symptoms.
4. The other stages - Prodromal, Incubation, and Convalescence - do not align with the client's current presentation as they represent different phases of an infection before or after the active illness period.
Summary:
A: Prodromal - Characterized by non-specific symptoms and mild discomfort, not severe sore throat and swollen lymph nodes.
B: Incubation - No symptoms present during this stage, so not applicable to the client's current condition.
C: Convalescence - Represents the recovery period after the illness, not the active symptomatic phase the client is currently