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: A negative Chvostek's sign is not expected in a client with hypocalcemia. The Chvostek's sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek's sign indicates neuromuscular irritability due to low calcium levels.
Therefore, a negative Chvostek's sign would not be consistent with hypocalcemia. A positive Trousseau's sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau's sign, indicating neuromuscular irritability due to low calcium levels. Muscle cramps are a common symptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort. Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention. Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.
Question 2 of 5
A nurse is preparing to assess a client's carotid arteries. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: Placing the client in a high-Fowler's position during the assessment is not necessary for assessing the carotid arteries. While this position can be useful for other assessments, it is not specifically required for carotid artery evaluation. The client can be in a seated or supine position with the head slightly elevated. Auscultating each carotid artery with the bell of the stethoscope is the most appropriate action. This technique allows the nurse to listen for bruits, which are abnormal sounds indicating turbulent blood flow due to partial obstruction or narrowing of the artery. Using the bell of the stethoscope is crucial because it is better suited for detecting low-pitched vascular sounds. Palpating the carotid arteries simultaneously is not recommended. Doing so can significantly reduce blood flow to the brain, potentially causing dizziness or fainting. Instead, each carotid artery should be palpated individually to assess the amplitude and contour of the pulse without compromising circulation. Massaging the carotid artery while assessing the client is inappropriate and potentially dangerous. Massaging the carotid artery can stimulate the carotid sinus, leading to a reflex drop in heart rate and blood pressure, which can cause syncope (fainting). This action should be avoided during assessment.
Question 3 of 5
A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: A,B,C,D,E
Rationale: Inspection (
A) comes first to observe visually, followed by auscultation (
B) to avoid altering bowel sounds, then percussion (
C) to assess underlying structures, light palpation (
D) to check tenderness, and deep palpation (E) to assess deeper structures like the aorta.
Question 4 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: Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties. Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client. Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor. Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.
Question 5 of 5
A charge nurse is teaching a group of nurses about decreasing the risk for catheter-associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?
Correct Answer: D
Rationale: Larger catheters (20 French) increase trauma risk; full bags risk backflow; disconnecting breaks sterility. Keeping the bag below bladder level prevents urine backflow, reducing infection risk.