ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Expose the client's abdomen to look for changes in appearance. This action should be taken first because sudden, severe abdominal pain postoperatively can indicate a serious complication like internal bleeding or bowel perforation. By exposing the abdomen, the nurse can visually assess for signs of distention, discoloration, or any other abnormality that may indicate a surgical complication. This visual assessment can provide crucial information to guide further interventions.
Choices A, B, and C involve assessment techniques that may be important in evaluating the client's condition, but they should be secondary to visually inspecting the abdomen in this urgent situation.
Choice A focuses on bowel sounds, which may not be reliable in a postoperative client experiencing sudden severe pain.
Choice B involves palpation, which could potentially exacerbate any existing complications.
Choice C refers to assessing areas of resonance, which is less urgent compared to visually inspecting for immediate changes in the abdomen.
In summary, visually inspecting the client's
Question 2 of 5
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Auscultate bowel sounds. This is the first action the nurse should take as it can provide crucial information about the client's condition, particularly in suspected appendicitis. Absence of bowel sounds in the right lower quadrant may indicate an inflamed appendix, requiring immediate medical attention. Administering an antiemetic (choice
A) or pain medication (choice
B) without assessing the bowel sounds first could mask important symptoms. Palpating the abdomen (choice
C) can potentially worsen the client's condition if appendicitis is present.
Therefore, auscultating bowel sounds is the priority to guide further assessment and intervention.
Question 3 of 5
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Review the use of an artificial larynx with the client. This is the priority as it directly addresses the client's immediate need for communication after a total laryngectomy. Using an artificial larynx can help the client communicate effectively post-surgery.
Choice A (Schedule a support session for the client) is important but not the priority.
Choices B (Explain the techniques of esophageal speech) and C (Determine the client's reading ability) are not as essential as ensuring immediate communication post-surgery.
Question 4 of 5
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Correct Answer: A
Rationale: The correct answer is A. The client's belief that his needs will be met through education is likely to increase motivation to learn because it aligns with the concept of self-determination theory. This theory posits that individuals are motivated when they perceive that their needs for autonomy, competence, and relatedness are met. In this case, the client believing that his needs will be met through education satisfies his need for competence in managing his health.
Choice B is incorrect because simply being told the need for education may not necessarily increase motivation without the client perceiving a personal benefit.
Choice C is incorrect as seeking family approval is an external motivator and may not necessarily lead to sustained motivation.
Choice D is incorrect as empathy from the nurse, while important, may not directly impact the client's motivation to learn.
Question 5 of 5
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct
Answer: B - The scale measures six elements.
Rationale: The Braden scale is used to assess a patient's risk for developing pressure ulcers and consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Understanding this indicates knowledge of the scale's components.
Incorrect
Choices:
A: Each element has a range from one to five points - This is incorrect because the elements are not scored on a range from one to five.
C: The client's age is part of the measurement - Age is not a factor in the Braden scale assessment.
D: The higher the score, the higher the pressure injury risk - This is incorrect as a higher score on the Braden scale indicates a lower risk of pressure ulcers.