ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client brought to the emergency room. The client’s caregiver reports the client had a sudden onset of confusion. Which intervening technique by the nurse is most appropriate to evaluate mentation for this client?
Correct Answer: B
Rationale: Open-ended questions allow comprehensive assessment of thought processes orientation and cognitive function in sudden confusion. Close-ended (
A) directive (
C) and reflective (
D) questions are less effective for initial mental status evaluation.
Question 2 of 5
A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?
Correct Answer: D
Rationale: Keeping the IV line open with 0.9% normal saline through new tubing is the first priority to maintain access for emergency treatments. This ensures hydration and readiness for medications, preceding provider notification, blood bank reporting, or urine collection.
Question 3 of 5
A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?
Correct Answer: A
Rationale: Cranial nerve V (trigeminal) is assessed by testing motor function (clenching teeth to evaluate masseter/temporalis strength) and sensory function (light touch on facial areas). Clenching teeth (
B) assesses motor function but sensory assessment is also required for a complete evaluation making A (clench teeth and assess sensation) the standard. Listening to speech (
A) reading a Snellen chart (
C) and raising eyebrows (
D) assess other cranial nerves.
Question 4 of 5
A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?
Correct Answer: B
Rationale: Gown and gloves prevent contact transmission of C. difficile. Masks are unnecessary, alcohol-based sanitizers are ineffective against spores, and blood tests don’t diagnose C. difficile.
Question 5 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.