ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
Correct Answer: A, C, E
Rationale:
Correct Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity and rest helps reduce metabolic demands, allowing the body to focus on fighting the infection and promoting healing.
E: Assisting the client with oral hygiene frequently is important to prevent further infection and maintain oral health, especially in older adults who may have compromised immune systems.
Summary:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential for maintaining fluid balance and aiding in infection recovery.
D: Allowing the client to shiver to dispel excess heat is not advised as it can lead to increased metabolic demands and potential complications.
F, G: No other choices are provided in the question.
Question 2 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 3 of 5
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. This is because asking about nausea and vomiting helps the nurse understand if the abdominal pain may be related to gastrointestinal issues or other underlying conditions. This information provides important context for the assessment and can guide further evaluation and treatment.
Summary of other choices:
B: Location of the pain - While important, knowing the location alone does not provide insight into potential causes or severity.
C: Pain quality - Important for understanding the nature of pain but does not specifically address associated symptoms.
D: Aggravating & relieving factors - Relevant for understanding pain triggers but does not directly address associated symptoms.
Question 4 of 5
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by a high body temperature, which can lead to vasodilation and decreased blood pressure, resulting in hypotension. Bradycardia (choice
B) is unlikely as the body tries to compensate by increasing heart rate. Clammy skin (choice
C) is more indicative of shock rather than heat stroke. Bradypnea (choice
D) is unlikely as the body tries to increase respiratory rate in response to heat stress.
Question 5 of 5
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Repeating the prescription details back ensures accurate communication and confirms understanding.
B: Having another nurse listen provides a second verification to prevent errors or misinterpretations.
C: Obtaining the prescriber's signature is essential for legal documentation and accountability.
Summary:
D: Declining the prescription is inappropriate as it disregards the client's pain management needs.
E: Informing the charge nurse alone does not fulfill the necessary steps to ensure safe medication administration.