ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Nurses’ Notes
First Clinic Vist:
Cliet arrives to dinc with report of increasing shortness of breath, fatigue. and weakness. States they gt short of breath with minimal activiy.
Cllent s alert and oriented to person, pace, and time. Maoves allextremities well, follows simple commands. Sinus tachycardia, Pulses to lowr extremitis wesk with +2 dependent edema present,
Slightlylabored respirations at rst. Chest with wheezes and crackles n the basas. Reports productive cough, especially during the overnight hours.
Bowel sounds al presen. Abdomen distended. Reports bowel movement this am.
States voiding without dfficulty, lear yellow urine
Teaching provided on nuition therapy and adhering to & ow-sodium diet, monitoring fud intake, and Ifestyle changes for heart fallure. Provided medication teaching following provider's increase in furosemide dosage
Question 1 of 5
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure because it indicates potential fluid buildup in the lungs, known as pulmonary edema, which can lead to severe respiratory distress and compromise oxygenation. Wheezes suggest bronchoconstriction, while crackles indicate fluid in the alveoli. These signs are indicative of worsening heart failure and require immediate intervention.
Weak pulses with +2 dependent edema in lower extremities (
Choice
A) are expected findings in heart failure due to fluid retention, but they do not directly indicate acute respiratory compromise. Slightly labored respirations at rest (
Choice
B) may be common in heart failure, but they are not as concerning as the presence of wheezes and crackles. Reports of productive cough during overnight hours (
Choice
D) may suggest underlying respiratory infection but are not as urgent as the respiratory distress indicated by wheezes and crackles.
Extract:
Question 2 of 5
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should first reflect on their own values and beliefs to ensure they are not influencing their judgment. This is important in maintaining objectivity and providing unbiased care.
Choice B is incorrect as it disregards the parents' autonomy and fails to address their concerns.
Choice C is incorrect as it violates the parents' right to make healthcare decisions for their child.
Choice D may be helpful but should not be the first step. Overall, respecting the parents' beliefs and engaging in open communication is key in this situation.
Question 3 of 5
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
Correct Answer: A
Rationale:
Rationale:
Choice A is correct as documenting the provider's instructions in the medical record ensures clear communication and accountability. This helps track the client's condition and the actions taken.
Choices B, C, and D are incorrect as they do not address the immediate need to follow the surgeon's instructions. The priority is to ensure the client's vital signs are monitored as directed.
Extract:
Nurses' Notes: Day 1
Lactated Ringer'sat 100 mbhr infusing into a 20-guage IV catheter in left hand. IV ressing dry and Intact. IV site without redness or swelling. IV fluld infusing vl [ Place a pressure chessing over the IV site.
(03 Apply heat to the clients left hand.
Day2 [ start.a newIV inthe clent’s eft hand. IV site edematous. Skin surrounding catheter site taut blanched, and cool to touch. IV fluid not nfusing.
Question 4 of 5
A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The client's IV site is showing signs of infiltration (edematous, cool skin, IV fluid not infusing), which can lead to tissue damage. Stopping the infusion is crucial to prevent further harm.
B: Place a pressure dressing over the IV site - A pressure dressing can help reduce swelling and prevent further infiltration of fluid into the surrounding tissues.
C: Apply heat to the client's left hand - Applying heat can help dilate blood vessels and improve circulation, which may help reduce the effects of infiltration and promote tissue healing.
Summary of Incorrect
Choices:
D: Starting a new IV in a different site is not necessary at this moment. The priority is to address the infiltration issue with the current IV.
E, F, G: No additional choices were provided, but they would likely be incorrect as they do not address the immediate concern of the IV site infiltration.
Extract:
Nurses’ Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackies heard n left upper lobe and decraased braath sounds at bases bilaterally. 0 Heartate
s
Question 5 of 5
A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, requiring follow-up. Oxygen saturation of 88% is below the normal range (95-100%), indicating hypoxemia. A heart rate of 98 beats/min is elevated, possibly due to hypoxemia or increased work of breathing. Blood pressure of 130/80 mmHg is within normal limits. Crackles in the left upper lobe and decreased breath sounds suggest lung pathology but do not require immediate follow-up.