ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
Question 1 of 5
A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?
Correct Answer: A
Rationale: The correct answer is A: Auscultate lung sounds. This is the priority assessment when administering fluids as it helps detect fluid overload, a potentially life-threatening adverse effect. Lung sounds can reveal signs of pulmonary edema, such as crackles, indicating fluid accumulation in the lungs. Monitoring urine output (
B) is important but not as immediate as assessing for respiratory distress. Blood pressure readings (
C) and electrolyte levels (
D) are important in assessing fluid status, but they do not provide immediate information on respiratory status.
Question 2 of 5
The client is experiencing symptoms of itching and anxiety, and presents with a flushed face and hives. Complete the following sentence: 'The client's condition is indicative of _.'.
Correct Answer: A
Rationale: The correct answer is A: An allergic reaction. The symptoms described - itching, anxiety, flushed face, and hives - are classic signs of an allergic reaction. Itching and hives suggest a skin reaction, while anxiety can be a psychological response to the physical symptoms. Flushed face may indicate a systemic response. The presence of these symptoms together points towards an immune response triggered by an allergen.
Choices B, C, and D are incorrect as they do not align with the symptoms presented.
Choice B mentions side effects of a procedure, which would not typically cause these specific symptoms.
Choice C, anxiety disorder, does not explain the physical symptoms like itching and hives.
Choice D, hypersensitivity to IV gauge material, could be a potential cause, but the broader symptoms described are more indicative of an allergic reaction.
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 3 of 5
Which findings require intervention by the nurse?
Correct Answer: A,B,C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Passive range-of-motion exercises to lower extremities performed once each day are important to prevent contractures and maintain joint mobility in immobile patients.
B: Left heel with nonblanchable erythema indicates a pressure injury or early sign of skin breakdown, requiring intervention to prevent further damage.
C: Plantar flexion contractures can lead to foot drop and impair mobility, so early intervention is necessary to prevent complications.
Summary:
D: Pedal pulses 2+ bilaterally indicate good circulation, which does not require immediate intervention.
E, F, G: Insufficient information provided to determine if these findings require immediate intervention.
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 4 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 correct answer is D: Obtain an electrocardiogram (ECG). The client's symptoms of sudden shortness of breath and chest tightness, along with her history of hypertension and diabetes, raise concerns for a possible cardiac event such as a heart attack. An ECG is crucial for promptly identifying any cardiac abnormalities and guiding further treatment. It provides valuable information on the heart's electrical activity, helping to assess for signs of ischemia or arrhythmias. Initiating a cardiac enzyme panel (choice
A) may be necessary later but obtaining an ECG takes priority for immediate assessment. Starting IV fluid therapy (choice
B), providing pain relief medication (choice
C), performing a comprehensive physical assessment (choice E) are important interventions but obtaining an ECG is the most urgent action to rule out a cardiac emergency in this scenario.
Extract:
A nurse is caring for a patient in a medical-surgical unit.
The patient’s current diagnoses include type 2 diabetes mellitus and a past medical history of a left below-the-knee amputation 5 years ago.
The nurse is at the patient’s bedside for a dressing change.
The patient’s heart sounds (S1 and S2) are auscultated, with a rate of 76/min. The patient’s respirations are even and regular at 16/min.
The negative pressure wound therapy dressing is removed. Granulation tissue covers the wound bed.
There is slight erythema at the wound edges. The surrounding tissue is warm to touch.
There is no odor present.
The pressure injury is 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point.
There are two tunnels measuring 5 cm (2 in) and 3 cm (1.2 in). The dressing is reapplied and sealed.
The intermittent pressure setting is at 125 mm Hg. The patient reports pain as a 2 on a scale from 0 to 10 and tolerated the procedure well.
Question 5 of 5
Which of the following findings indicate an improvement in the patient's condition?
Correct Answer: A
Rationale: The correct answer is A because granulation tissue covering the wound bed indicates healing progress by promoting tissue repair and regeneration. This is a positive sign of wound healing.
Choice B, slight erythema at wound edges, can indicate inflammation or infection, not necessarily improvement.
Choice C, warm surrounding tissue, could suggest infection or inflammation, not improvement.
Choice D, pain level 2, is subjective and doesn't directly indicate improvement in the condition.