ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E. Hypocalcemia results in low levels of calcium in the blood. A positive Trousseau's sign, muscle cramps, and tingling sensation around the lips are common manifestations due to neuromuscular irritability.
A negative Chvostek's sign is associated with hypocalcemia, not a positive one. Abdominal distention is not a typical finding in hypocalcemia.
In summary, the correct choices align with the typical signs and symptoms of hypocalcemia related to neuromuscular irritability, while the incorrect choices do not correlate with this condition.
Question 2 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: The correct answer is B: Administers an analgesic medication 5 minutes before starting irrigation. Administering an analgesic medication before wound irrigation helps to manage the client's pain during the procedure, promoting comfort and compliance. This action indicates the staff nurse's understanding of the importance of pain management in wound care.
Rationale for why the other choices are incorrect:
A: Refrigerating the solution before irrigation is unnecessary and may cause discomfort to the client due to the cold temperature.
C: Using one pair of gloves for dressing removal and irrigation increases the risk of cross-contamination and infection.
D: Using a syringe with a catheter for wound irrigation is not the standard practice for pressure injury wound irrigation and may not provide effective cleansing of the wound.
Question 3 of 5
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Allow the client to slide down their outstretched leg. This is the safest option as it helps to lower the client to the ground in a controlled manner, reducing the risk of injury. Moving quickly in front of the client (
A) can potentially cause both the nurse and the client to fall. Remaining upright (
B) increases the risk of injury to both parties. Placing arms around the client (
D) may not provide enough support and could lead to both falling. It's important for the nurse to prioritize the safety of the client by guiding them down gently.
Question 4 of 5
A nurse is caring for a client who has an NG tube set to low-intermittent suction for gastric decompression. The nurse observes that the NG tube is not draining. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Inject 10 mL of air into the vent lumen. Injecting air into the vent lumen can help to clear any blockage in the NG tube and facilitate drainage. This action creates pressure within the tube, potentially dislodging any obstruction. Lowering the head of the client's bed to 15 degrees (
Choice
A) may help prevent aspiration but will not address the issue of the tube not draining. Placing the NG tube to high suction (
Choice
C) can be harmful and is not indicated for gastric decompression. Connecting the air vent to the suction (
Choice
D) would not resolve the drainage issue and can interfere with the functioning of the NG tube.
Question 5 of 5
A nurse is caring for a client who is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Insert an indwelling urinary catheter and connect it to gravity drainage. In this situation, the client is showing signs of urinary retention, which can lead to serious complications if not addressed promptly. By inserting a urinary catheter, the nurse can help relieve the client's discomfort and prevent further complications such as bladder distention or urinary tract infections. Connecting it to gravity drainage allows for proper drainage of urine.
Choice A is incorrect because simply hearing running water may not be effective in helping the client void.
Choice B is incorrect as encouraging fluid intake may exacerbate the issue if the client is already having difficulty voiding.
Choice C is incorrect as providing a bedpan while lying supine is not an appropriate position for voiding. It may further hinder the client's ability to void.