ATI RN
ATI RN Fundamentals Exam 6 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following indicates fluid volume deficit?
Correct Answer: D
Rationale: Decreased hematocrit may be seen in fluid volume excess not deficit. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit. Increased skin turgor is a clinical manifestation of fluid volume deficit. Increased pulse rate is a compensatory response to fluid volume deficit reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.
Question 2 of 5
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Sterile gloves are not necessary for a tap water enema; clean non-sterile gloves are sufficient. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema. Lowering not raising the enema bag will allow for a slower flow and may reduce cramping.
Question 3 of 5
A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse make sure is readily available at the client's bedside?
Correct Answer: C
Rationale: Vest restraints are not appropriate for seizure precautions. Restraints are generally not recommended as the primary intervention for seizure management. The use of tongue blades during a seizure is not recommended and could pose a risk of injury. Oxygen setup is crucial for managing a client during and after a seizure to ensure proper oxygenation. Neck brace is not necessary for seizure precautions and may pose a risk during a seizure episode.
Question 4 of 5
A nurse is evaluating a client's use of crutches. Which of the following observations indicates safe use of this equipment?
Correct Answer: D
Rationale: Placing one crutch on each side when assuming a sitting position is not the correct technique. The client should use both crutches on one side to provide support when sitting or rising. Placing weight on the axillae when walking can cause nerve damage and is an incorrect crutch-walking technique. The client should bear weight on the hands and arms not the axillae. Moving the unaffected leg onto a step first when descending stairs is a correct and safe technique for using crutches on stairs. Having slightly flexed elbows when ambulating with crutches is a proper technique for maintaining balance and support while walking.
Question 5 of 5
A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?
Correct Answer: A
Rationale: Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions. Postural drainage is typically done before meals to avoid potential nausea during the procedure. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.