ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Edema and distended neck veins indicate fluid overload, not deficit. Postural hypotension occurs due to reduced blood volume, causing dizziness upon standing. Tachycardia, not bradycardia, is expected as a compensatory response to fluid loss.
Question 2 of 5
A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?
Correct Answer: C
Rationale: Self-care incapacity or terminal illness doesn’t automatically trigger it; it’s enforceable when the client can’t express wishes due to incapacity. Refusal of treatment doesn’t activate it if the client is competent.
Question 3 of 5
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A,E
Rationale: Cutting the pouch opening 1/8 inch larger ensures a proper fit, preventing skin irritation. Using gauze is a practical tip but not a core instruction. A purple-blue stoma indicates poor blood flow, not healing, and requires medical attention. Povidone-iodine is too harsh; mild soap and water are recommended. Emptying the pouch at one-third full prevents leaks and maintains hygiene.
Question 4 of 5
A nurse is preparing to administer cefoxitin 80 mg/kg/day IV every 6 hours to a 6 year-old child who weighs 20 kg. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 400
Rationale:
Step 1: Calculate the total daily dosage in mg. 80 mg/kg/day × 20 kg = 1600 mg/day.
Step 2: Determine the number of doses per day. 24 hours ÷ 6 hours = 4 doses/day.
Step 3: Calculate the dosage per dose. 1600 mg/day ÷ 4 doses/day = 400 mg/dose. The nurse should administer 400 mg per dose.
Question 5 of 5
A nurse is preparing to assess a client's carotid arteries. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: Placing the client in a high-Fowler's position during the assessment is not necessary for assessing the carotid arteries. While this position can be useful for other assessments, it is not specifically required for carotid artery evaluation. The client can be in a seated or supine position with the head slightly elevated. Auscultating each carotid artery with the bell of the stethoscope is the most appropriate action. This technique allows the nurse to listen for bruits, which are abnormal sounds indicating turbulent blood flow due to partial obstruction or narrowing of the artery. Using the bell of the stethoscope is crucial because it is better suited for detecting low-pitched vascular sounds. Palpating the carotid arteries simultaneously is not recommended. Doing so can significantly reduce blood flow to the brain, potentially causing dizziness or fainting. Instead, each carotid artery should be palpated individually to assess the amplitude and contour of the pulse without compromising circulation. Massaging the carotid artery while assessing the client is inappropriate and potentially dangerous. Massaging the carotid artery can stimulate the carotid sinus, leading to a reflex drop in heart rate and blood pressure, which can cause syncope (fainting). This action should be avoided during assessment.