ATI RN
ATI RN Fundamentals Exam 6 Questions
Extract:
Question 1 of 5
A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?
Correct Answer: D
Rationale: A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided. A client who received a diuretic 30 min ago may experience orthostatic hypotension which can increase the risk of falling but it is not the highest risk. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness disorientation or postictal state following the seizure.
Question 2 of 5
A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following indicates fluid volume deficit?
Correct Answer: D
Rationale: Decreased hematocrit may be seen in fluid volume excess not deficit. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit. Increased skin turgor is a clinical manifestation of fluid volume deficit. Increased pulse rate is a compensatory response to fluid volume deficit reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.
Question 3 of 5
A nurse is assessing a client's lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?
Correct Answer: C
Rationale: 1+ pitting edema is mild with a slight indentation. 4+ pitting edema is severe with a deep indentation that lasts a long time. 3+ pitting edema is moderate with a deeper indentation that takes some time to rebound. 2+ pitting edema is moderate with a slight indentation that rebounds fairly quickly.
Question 4 of 5
A nurse is caring for a client who has a stage II pressure ulcer. Which of the following products should the nurse use to treat the ulcer?
Correct Answer: B
Rationale: Granulex is a topical medication used for wound care but it may not be the first choice for a stage II pressure ulcer. Hydrocolloid dressings are appropriate for stage II pressure ulcers providing a moist environment to support healing and protecting the wound from contamination. Proteolytic enzymes are used for debridement of necrotic tissue and may not be the primary choice for a stage II pressure ulcer. Cortisone cream is a topical steroid that may be used for certain skin conditions but is not typically the first-line treatment for pressure ulcers.
Question 5 of 5
A nurse is calculating the 8-hr fluid intake for a client who is receiving IV fluids and a clear liquid diet. The client had 880 mL of dextrose 5% in water IV bolus a 6 oz cup of tea 4 oz of apple juice 8 oz of water 3 oz of flavored gelatin and 6 oz of broth. What should the nurse document as the client's 8-hr fluid intake? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.)
Correct Answer: 1690
Rationale:
To calculate the 8-hr fluid intake convert all measurements to milliliters (mL). 1 oz = 30 mL so 6 oz of tea = 180 mL 4 oz of apple juice = 120 mL 8 oz of water = 240 mL 3 oz of flavored gelatin = 90 mL and 6 oz of broth = 180 mL. Add up all the fluid intake from IV fluids and clear liquids: 880 + 180 + 120 + 240 + 90 + 180 = 1690 mL. Round the answer to the nearest whole number: 1690 mL. The nurse should document 1690 mL as the client's 8-hr fluid intake.