ATI RN
ATI Fundamental Proctored Exam 2024-2025 Online Practice 250 Simulated Exam Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
Correct Answer: B
Rationale: The correct answer is B: Client's self-report of pain. This is the most reliable source for determining the intensity of the client's pain because pain is a subjective experience and can vary greatly among individuals. The client is the best source to accurately describe their pain level, location, and quality. Vital sign measurements (
A) may provide some indication of pain, but they are not as accurate as the client's self-report. Visual observation (
C) may be helpful, but it can be subjective and may not always correlate with the client's actual pain level. The nature of invasiveness of the surgical procedure (
D) may give some indication of potential pain level, but it does not directly measure the client's current pain intensity.
Question 2 of 5
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take when a client begins to fall during ambulation is to lower the client to the floor (
Choice
C). This is the safest option to prevent further injury to the client. Lowering the client to the floor helps minimize the distance of the fall, reducing the risk of serious injury. Additionally, it allows for a controlled descent, ensuring the client lands safely. Providing support by holding the client's arm (
Choice
A) may not be enough to prevent a fall and could lead to both the nurse and the client getting injured. Leaning the client toward the wall (
Choice
B) may not provide adequate support and could still result in a fall. Maintaining a narrow base of support (
Choice
D) may not be effective in preventing a fall. The best course of action is to prioritize the safety of the client by lowering them to the floor in a controlled manner.
Question 3 of 5
A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (
Choice
C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (
Choice
A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (
Choice
B) could also be difficult for a left-handed nurse and may affect dexterity.
Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.
Question 4 of 5
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
Correct Answer: A,C,D
Rationale: The correct actions to contribute to the fall prevention plan are A, C, and D. A night light can help the client see clearly at night, reducing the risk of tripping. Locking the wheels on beds and wheelchairs ensures stability during transfers. Placing the bedside table within reach promotes independence and prevents falls from reaching for items.
Choice B is incorrect as bed height doesn't directly impact fall risk.
Choice E, administering a sedative, can increase fall risk due to drowsiness.
Question 5 of 5
A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?
Correct Answer: C
Rationale: The correct answer is C: BUN 28 mg/dL. An elevated BUN level indicates poor protein metabolism, which could be a sign that the current enteral formula is not being adequately utilized by the client. This could lead to malnutrition or other complications.
A: Hematocrit measures the volume percentage of red blood cells in blood. It is not directly related to enteral feedings.
B: Urine specific gravity reflects hydration status and kidney function, not related to enteral feedings.
D: Sodium level is not specific to enteral feedings.
In summary, an elevated BUN level signifies poor protein metabolism and indicates a need for a change in the enteral formula to better meet the client's nutritional needs.