ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 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 guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate.
Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.
Question 2 of 5
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice
A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice
C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice
D) is not as proactive as addressing the potential pain issue immediately.
Question 3 of 5
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
Correct Answer: D
Rationale: The correct answer is D because a contaminated specimen can lead to false results. The client should be instructed to avoid contaminating the specimen with urine, water, or toilet bowl cleaners.
Choice A is incorrect because protein intake does not affect the test.
Choice B is incorrect as multiple stool specimens are usually required.
Choice C is incorrect as a blue color change indicates a positive test, not red.
Question 4 of 5
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (
A) and rice pudding & ripe bananas (
C) are low in fiber and may worsen constipation. Roast chicken & white rice (
D) lack sufficient fiber to alleviate constipation.
Question 5 of 5
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (
B) due to decreased blood volume, fever (
C) as a result of dehydration and infection, and poor skin turgor (
D) due to decreased tissue hydration. Bradycardia (
A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.