ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. This is because asking about nausea and vomiting helps the nurse understand if the abdominal pain may be related to gastrointestinal issues or other underlying conditions. This information provides important context for the assessment and can guide further evaluation and treatment.
Summary of other choices:
B: Location of the pain - While important, knowing the location alone does not provide insight into potential causes or severity.
C: Pain quality - Important for understanding the nature of pain but does not specifically address associated symptoms.
D: Aggravating & relieving factors - Relevant for understanding pain triggers but does not directly address associated symptoms.
Question 2 of 5
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Warming the enema helps prevent cramping and discomfort during instillation.
B: Positioning the client on the left side with the right leg flexed forward helps facilitate easier insertion of the enema.
C: Lubricating the rectal tube or nozzle helps prevent injury and discomfort during insertion.
Incorrect
Choices:
D: Slowly inserting the rectal tube about 2 inches is incorrect as it may not be deep enough to reach the sigmoid colon.
E: Hanging the enema container 24 inches above the client's anus is incorrect as it may cause rapid flow leading to discomfort and cramping.
Question 3 of 5
A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
Correct Answer: B
Rationale: The correct answer is B: Checking with the provider when a single dose requires administration of multiple tablets. This action indicates an understanding of med error prevention because it ensures the medication is being administered correctly as per the provider's instructions. By verifying with the provider for doses that require multiple tablets, the nurse is practicing safe medication administration and preventing dosing errors.
Explanation for other choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room - This is incorrect as it increases the risk of medication mix-ups and errors.
C: Administering a med, then looking up the usual dosage range - This is incorrect as it should be done before administering the medication to ensure the correct dosage is given.
D: Relying on another nurse to clarify a med prescription - This is incorrect as each nurse should take responsibility for verifying and understanding medication orders independently.
Question 4 of 5
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
B: Nail polish should not be used near a client receiving oxygen as it is flammable and can ignite easily, posing a fire hazard.
C: A 'No smoking' sign should be placed on the front door to remind everyone that smoking is prohibited in the presence of oxygen, reducing the risk of fire.
E: A fire extinguisher should be readily available in the home to quickly extinguish any fire that may occur due to oxygen use, ensuring safety.
Incorrect
Choices:
A: Family members who smoke must be at least 10 ft from the client when oxygen is in use is important, but it is more crucial to prevent any source of ignition near oxygen.
D: Cotton bedding & clothing should not be replaced with items made from wool specifically due to oxygen use. It is unnecessary and not related to oxygen safety.
Question 5 of 5
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and the heel-to-toe walk. The Romberg test evaluates the client's ability to maintain balance with eyes closed, assessing proprioception. The heel-to-toe walk tests balance, coordination, and gait, evaluating the client's ability to walk in a straight line. The Snellen test assesses visual acuity, not balance. Spinal accessory function evaluates shoulder movement, not balance. The Rosenbaum test is used to assess near vision, not balance.