ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
Correct Answer: D
Rationale:
Correct Answer: D (Illness)
Rationale:
1. The client is experiencing symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes, indicating an active infection.
2. The illness stage is characterized by the manifestation of specific symptoms as the body tries to fight off the infection.
3. During the illness stage, the infection is fully developed and the individual exhibits overt signs and symptoms.
4. The other stages - Prodromal, Incubation, and Convalescence - do not align with the client's current presentation as they represent different phases of an infection before or after the active illness period.
Summary:
A: Prodromal - Characterized by non-specific symptoms and mild discomfort, not severe sore throat and swollen lymph nodes.
B: Incubation - No symptoms present during this stage, so not applicable to the client's current condition.
C: Convalescence - Represents the recovery period after the illness, not the active symptomatic phase the client is currently
Question 2 of 5
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?
Correct Answer: D
Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis and maintain lung expansion in immobile clients. Isometric exercises (
A) are not directly related to airway patency. Suctioning (
B) every 8 hours is not necessary unless there are secretions. Low-dose heparin (
C) is used for preventing blood clots, not for airway maintenance.
Question 3 of 5
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
Correct Answer: D
Rationale: The correct answer is D: Pain is whatever the client says it is. This principle is based on the concept of respecting the client's subjective experience of pain. Pain is a personal and individualized experience, and the client's perception and description of pain are crucial in guiding assessment and treatment. By acknowledging and accepting the client's self-report of pain, the nurse can provide more effective and compassionate care.
Other choices are incorrect:
A: Some clients exaggerate their level of pain - This choice assumes a negative bias towards clients and disregards the importance of validating their pain experience.
B: Pain must have an identifiable source to justify the use of opioids - This choice imposes unnecessary criteria for pain management and may lead to under-treatment of pain.
C: Objective data are essential in assessing pain - While objective data can complement pain assessment, they should not override the client's subjective experience as the primary guide for pain management.
Question 4 of 5
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. The rationale is that occupational therapists specialize in helping individuals with physical limitations achieve independence in daily activities, such as self-feeding. They can assess the client's needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Referring the client to an occupational therapist ensures personalized and effective intervention.
Choices A, B, and C are incorrect as they do not have the specific expertise in addressing self-feeding difficulties due to rheumatoid arthritis.
Question 5 of 5
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
Correct Answer: A, B, C
Rationale: The correct answer includes guidelines A, B, and C. Placing the client in semi-Fowler's position allows for easier chest expansion. Having the client rest an arm across the abdomen helps to promote relaxation and allows for easier observation of respiratory movements. Observing one full respiratory cycle before counting the rate ensures an accurate assessment. Guidelines D and E are incorrect. Counting the rate for one minute is unnecessary if the rate is regular; it can be counted for 30 seconds and then doubled. Reporting sighs is not a standard practice in measuring respiratory rate and is not relevant to the assessment.