ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
Correct Answer: A
Rationale: Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell's palsy or a stroke. The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve.
Therefore, this response is not relevant to the assessment of cranial nerve VII. Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve. Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.
Question 2 of 5
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
Correct Answer: C
Rationale: The four-point alternating gait is used when a client can bear weight on both legs. This gait provides maximum stability and is often used for clients with poor balance or coordination. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. Since the client can only bear weight on one leg, this gait is not appropriate. The two-point alternating gait is also used when a client can bear weight on both legs. It is faster than the four-point gait and involves moving one crutch and the opposite leg simultaneously, followed by the other crutch and the opposite leg. This gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg. The three-point gait is specifically designed for clients who can only bear weight on one leg. In this gait, both crutches are moved forward together, followed by the weight-bearing leg. The non-weight-bearing leg is then swung through. This gait provides the necessary support and stability for clients with one non-weight-bearing leg, making it the most appropriate choice in this scenario. The swing-through gait is used by clients who have good upper body strength and can bear weight on both legs, even if one leg is weaker. This gait involves moving both crutches forward together and then swinging both legs through to the crutches. It is not suitable for a client who can only bear weight on one leg, as it requires some degree of weight-bearing on both legs.
Question 3 of 5
A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?
Correct Answer: C
Rationale: Self-care incapacity or terminal illness doesn’t automatically trigger it; it’s enforceable when the client can’t express wishes due to incapacity. Refusal of treatment doesn’t activate it if the client is competent.
Question 4 of 5
A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Using sterile gloves to obtain the sputum specimen is important for maintaining sterility and preventing contamination. However, it is not the first priority action. The timing of the collection is more critical to ensure the accuracy and quality of the specimen. Obtaining the sputum specimen after the client uses mouthwash is incorrect. Mouthwash can kill or alter the microorganisms present in the sputum, leading to inaccurate test results. The client should rinse their mouth with water instead to reduce contamination from oral secretions. Collecting the sputum specimen in the morning is the most appropriate action. Sputum accumulates overnight, making it easier to collect a sufficient sample in the morning. This timing also ensures that the specimen is more concentrated and representative of the lower respiratory tract. Placing the sputum specimen in a clean container is necessary, but it is not the first action to take. The container should be sterile to prevent contamination and ensure the accuracy of the test results. However, the timing of the collection is more critical to obtaining a quality specimen.
Question 5 of 5
A charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: B
Rationale: Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process. Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client's pain during the procedure, ensuring comfort and compliance. Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique. Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.