ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is 2 days postoperative and is auscultating their bilateral breath sounds. The nurse notes absent breath sounds in the bases. The nurse should suspect which postoperative complication is occurring in this client?
Correct Answer: A
Rationale: Absent breath sounds in the lung bases post-surgery suggest atelectasis, where alveoli collapse due to shallow breathing or immobility. Pulmonary embolism, arterial thrombus, or pneumonia typically present with other signs like crackles or systemic symptoms.
Question 2 of 5
A nurse is teaching a client who has left-sided weakness after a stroke on how to use a cane. What instructions should the nurse include?
Correct Answer: A
Rationale: Holding the cane on the right side supports the weaker left leg, enhancing balance. Advancing the strong leg with the cane, removing the rubber tip, or placing the cane too far ahead reduces stability.
Question 3 of 5
A nurse is demonstrating to a client how to perform diaphragmatic breathing. The nurse should educate the client to complete which action?
Correct Answer: D
Rationale: Tightening abdominal muscles during exhalation pushes the diaphragm up, enhancing air expulsion in diaphragmatic breathing. Shoulder raising leads to shallow breathing, mouth inhalation is less effective, and nose exhalation is not standard.
Question 4 of 5
A nurse is caring for a client with a chest tube. Which action should the nurse take?
Correct Answer: A
Rationale: Positioning the collection device below the chest uses gravity to ensure proper drainage and prevent backflow. Clamping risks complications, occlusive dressings are secondary, and emptying isn’t routine.
Question 5 of 5
A nurse is preparing an educational program about client confidentiality. The nurse should explain that nurses may share a client's protected health information with which individuals?
Correct Answer: C
Rationale: Health care team members involved in the client’s care can access protected health information under HIPAA to ensure safe treatment. Sharing with family, administrators, or clergy requires client consent or a specific need, which is not automatic.