ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, 'I am looking forward to seeing my grandchildren grow up.' The nurse should identify that the client is experiencing which of the following stages of grief?
Correct Answer: A
Rationale: Denial is the first stage of grief, where individuals refuse to accept the reality of their situation. In this case, the client is looking forward to a future event (seeing their grandchildren grow up) despite being diagnosed with a terminal illness. This indicates that the client is not acknowledging the severity of their condition and is instead holding onto a hopeful but unrealistic outcome. Denial serves as a defense mechanism to protect the individual from the immediate shock and pain of their diagnosis. Anger is the second stage of grief, characterized by feelings of frustration and helplessness. Individuals in this stage may direct their anger towards themselves, others, or the situation. The client's statement does not reflect anger or frustration but rather an unrealistic hope for the future, which aligns more with denial than anger. Bargaining is the third stage of grief, where individuals attempt to negotiate or make deals to alter their situation. This stage often involves 'if only' or 'what if' statements as the person tries to regain control. The client's statement does not indicate any form of negotiation or deal-making but rather a refusal to accept the reality of their terminal illness. Acceptance is the final stage of grief, where individuals come to terms with their situation and begin to plan for the future realistically. In this stage, there is an acknowledgment of the loss and a gradual adjustment to the new reality. The client's statement about looking forward to seeing their grandchildren grow up does not reflect acceptance but rather a denial of the terminal nature of their illness.
Question 2 of 5
A charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: B
Rationale: Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process. Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client's pain during the procedure, ensuring comfort and compliance. Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique. Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.
Question 3 of 5
A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
Correct Answer: B
Rationale: Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding. Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention. Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding. Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss.
Therefore, brisk capillary refill is not indicative of active bleeding.
Question 4 of 5
A nurse is assessing a client who has chronic pain. Which of the following findings is associated with chronic pain?
Correct Answer: D
Rationale: Constricted pupils relate to opioid use, not chronic pain itself. Bradycardia isn’t typical; diaphoresis is more acute. Depression is a common long-term effect of chronic pain due to its impact on quality of life.
Question 5 of 5
A nurse is teaching a group of older adult clients about medication safety. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: D
Rationale: Herbal supplements must be reported due to interactions; allergies can develop over time; stopping medication abruptly is unsafe. Food-drug interactions (e.g., grapefruit with statins) show understanding.