ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?
Correct Answer: B
Rationale: Daily weight measurement reliably detects fluid retention in CHF, as sudden weight gain indicates fluid accumulation. Cardiac monitoring, blood pressure, and urine output are useful but less direct for assessing fluid status.
Question 2 of 5
A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances? pH: 7.56 PaCO2: 55 mmHg HCO3: 33 mEq/L
Correct Answer: A
Rationale: pH 7.56 (high) and HCO3 33 mEq/L (high) indicate metabolic alkalosis with elevated PaCO2 (55 mmHg) suggesting respiratory compensation. Metabolic acidosis (
B) respiratory alkalosis (
C) and respiratory acidosis (
D) do not match the values.
Question 3 of 5
A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which statement would the nurse identify as an indication that the client needs additional education?
Correct Answer: C
Rationale: Bearing weight on axillas risks nerve damage; weight should be supported by arms/hands. Keeping spare tips (
A) inspecting crutches (
B) and using arms (
D) are correct practices.
Question 4 of 5
A nurse is caring for a client admitted with a rash. They are trying to rule out (r/o) varicella. Before entering the room, the nurse should be instructed to wear what kind of mask?
Correct Answer: A
Rationale: An N95 mask is required for varicella, an airborne disease, to protect against inhaling infectious particles. Surgical masks, no mask, or client-only masks do not provide adequate protection.
Question 5 of 5
A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?
Correct Answer: C
Rationale: Cyanotic digits indicate impaired circulation necessitating immediate loosening to prevent tissue damage. Full range of motion (
A) and no discomfort (
D) suggest adequate restraint fit while attempting to remove them (
B) requires monitoring not loosening.