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 pain intensity as pain is a subjective experience, varying greatly from person to person. The client is the best judge of their own pain levels. Vital sign measurement (
A) may provide some indication but cannot accurately reflect the intensity of pain. Visual observation (
C) can miss subtle signs or misinterpret them. The nature of the surgical procedure (
D) is not a direct indicator of pain intensity. It is crucial to prioritize the client's self-report for effective pain management.
Question 2 of 5
A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
Correct Answer: B
Rationale: The correct answer is B: Uses the side of a fingertip as the puncture site. This is the correct answer because using the side of a fingertip for blood glucose monitoring helps to minimize pain and discomfort for the client. The sides of the fingertips contain fewer nerve endings compared to the fingertips' pads, making it a less sensitive area for blood sampling. This method also reduces the risk of potential complications such as nerve damage or calluses.
Other choices are incorrect because:
A: Using the ball of a finger as the puncture site can be more painful due to the higher concentration of nerve endings in that area.
C: Avoiding the fingers of the dominant hand is not a necessary step for accurate blood glucose monitoring.
D: Avoiding the thumbs as puncture sites is irrelevant as thumbs are not commonly used for blood glucose monitoring and do not pose any specific risks.
Question 3 of 5
A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Poor skin turgor, hypotension, and flat neck veins indicate dehydration due to fluid loss. Bradycardia is incorrect; tachycardia is expected. Pale yellow urine suggests adequate hydration.
Question 4 of 5
A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Grasp a fold of skin on the client's forearm or near the sternum. This is the correct action because assessing skin turgor involves gently lifting the skin to check for its elasticity and hydration status. Grasping a fold of skin on the forearm or near the sternum allows the nurse to evaluate how quickly the skin returns to its normal position after being pinched, indicating the level of hydration. Lightly palpating the skin (
A) does not provide an accurate assessment of skin turgor. Pressing the skin over the ankle bone (
B) or observing for red or purple spots on the abdomen (
C) are not relevant to assessing skin turgor.
Question 5 of 5
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A - Count the apical pulsations for a full minute.
Rationale: Counting the apical pulse for a full minute is essential to accurately determine the heart rate, especially in clients taking cardiovascular medications that can affect heart rate. This method provides a more precise measurement and helps in detecting any irregularities or changes in the heart rhythm.
Incorrect
Choices:
B: Checking the apical pulse with a Doppler device is not necessary for routine assessment and may not provide an accurate heart rate measurement.
C: Using the diaphragm of the stethoscope is appropriate, but the key point is to count the pulsations for a full minute.
D: Pressing the stethoscope firmly against the client's skin may impede the sound transmission and can lead to inaccurate readings.