ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
Correct Answer: B
Rationale: The correct answer is B. The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or fears, the nurse can address them effectively. This approach promotes client-centered care and helps in creating a supportive environment for the client's recovery. Requesting a respiratory therapist (choice
A) is not the priority as the client's refusal needs to be addressed first. Documenting the client's refusal (choice
C) is important but does not address the underlying issue. Administering pain medication (choice
D) is not the priority as it does not address the client's refusal.
Question 2 of 5
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Correct Answer: C
Rationale: The correct answer is C: Decrease in heart rate. Administering 0.9% sodium chloride helps to restore fluid volume in a client with fluid deficit. As the fluid level increases, the heart doesn't have to work as hard to pump blood, leading to a decrease in heart rate. This change indicates that the treatment was successful as it shows improvement in the client's condition.
Other choices are incorrect because:
A: Increase in hematocrit - This would indicate dehydration rather than successful treatment.
B: Increase in respiratory rate - This could suggest respiratory distress, not successful treatment for fluid volume deficit.
D: Decrease in capillary refill time - While this is a good indicator of perfusion, it may not directly reflect the success of fluid resuscitation in this scenario.
Extract:
Nurses’ Notes
First Clinic Vist:
Cliet arrives to dinc with report of increasing shortness of breath, fatigue. and weakness. States they gt short of breath with minimal activiy.
Cllent s alert and oriented to person, pace, and time. Maoves allextremities well, follows simple commands. Sinus tachycardia, Pulses to lowr extremitis wesk with +2 dependent edema present,
Slightlylabored respirations at rst. Chest with wheezes and crackles n the basas. Reports productive cough, especially during the overnight hours.
Bowel sounds al presen. Abdomen distended. Reports bowel movement this am.
States voiding without dfficulty, lear yellow urine
Teaching provided on nuition therapy and adhering to & ow-sodium diet, monitoring fud intake, and Ifestyle changes for heart fallure. Provided medication teaching following provider's increase in furosemide dosage
Question 3 of 5
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure because it indicates potential fluid buildup in the lungs, known as pulmonary edema, which can lead to severe respiratory distress and compromise oxygenation. Wheezes suggest bronchoconstriction, while crackles indicate fluid in the alveoli. These signs are indicative of worsening heart failure and require immediate intervention.
Weak pulses with +2 dependent edema in lower extremities (
Choice
A) are expected findings in heart failure due to fluid retention, but they do not directly indicate acute respiratory compromise. Slightly labored respirations at rest (
Choice
B) may be common in heart failure, but they are not as concerning as the presence of wheezes and crackles. Reports of productive cough during overnight hours (
Choice
D) may suggest underlying respiratory infection but are not as urgent as the respiratory distress indicated by wheezes and crackles.
Extract:
Nurses' Notes O Measure the clents intake and output,
1000; O Transfer the client from wheelchar o bed. Client states, *| am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that painisa"7" 0na 01010 pain L] Colect datasbout the clents pain evel. scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fuids started and infusing in lefc peripheral IV site
Question 4 of 5
A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) and helps monitor the client's condition.
B: Measuring intake and output is a task that can be delegated to an AP and is essential for assessing fluid balance.
C: Transferring the client from wheelchair to bed is a task that an AP can safely perform to assist with the client's mobility.
Incorrect
Choices:
D: Inserting an NG tube requires specialized training and is a nursing task that should not be delegated to an AP.
E:
F:
G:
Summary: The correct tasks delegated to an AP involve activities that are within their scope of practice and do not require specialized nursing skills. Tasks like measuring vital signs, intake and output, and assisting with transfers are appropriate for delegation to an AP, while tasks like inserting an NG tube should be performed by a nurse.
Extract:
Question 5 of 5
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
Correct Answer: D
Rationale: The correct answer is D: The client holds the cane on the stronger side of her body. This is correct because when using a cane, it should be held on the stronger side to provide support and stability. Placing the cane on the stronger side helps to offload weight from the weaker side, reducing the risk of falls.
Choice A is incorrect because the top of the cane should ideally be at the level of the greater trochanter, not necessarily parallel to the wrist.
Choice B is vague and does not indicate correct use.
Choice C is incorrect as there is no specific measurement for how far the cane should be moved forward.
Choice E is incorrect as the client should move the weaker limb forward with the cane for support.