ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
Correct Answer: A
Rationale: The correct answer is A: "Don't measure the client's temperature rectally." This is the priority instruction because clients with low platelet counts are at risk for bleeding easily. Rectal temperature measurements pose a higher risk for causing bleeding compared to other methods. It is crucial to avoid any unnecessary harm to the client.
Choice B is incorrect because counting the radial pulse and multiplying by 2 is a common method for measuring heart rate, but it is not the priority in this situation.
Choice C is incorrect because whether the client knows their respirations are being counted or not does not affect the accuracy of the vital sign measurement.
Choice D is incorrect because letting the client rest before measuring their blood pressure is a good practice, but it is not as critical as avoiding rectal temperature measurements in this scenario.
Question 2 of 5
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
Correct Answer: C
Rationale: The correct answer is C: Fastening her bra behind her back. Internal rotation of the shoulder is necessary for this activity. Internal rotation is when the shoulder rotates inward towards the body. When assessing internal rotation, the nurse is testing the range of motion in this direction. Activities like mopping floors, brushing hair, and reaching into a cabinet primarily involve shoulder flexion and abduction, not internal rotation.
Therefore, fastening a bra behind the back, which requires internal rotation, is the likely activity to be affected by the reported pain during internal rotation evaluation.
Question 3 of 5
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (Bradypnea), which the nurse should monitor for. Orthostatic hypotension can occur due to the vasodilatory effects of opioids. Nausea is a common side effect of opioids due to their effect on the gastrointestinal system. Urinary incontinence and diarrhea are not typical adverse effects of opioid analgesia, so choices A and B are incorrect.
Question 4 of 5
A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
Correct Answer: A, D
Rationale:
Correct Answer: A, D
Rationale:
A: Covering the area with saline-soaked sterile dressings helps to protect the exposed tissues from further contamination and dehydration.
D: Positioning the client supine with hips & knees bent helps reduce tension on the wound site and prevent further protrusion of viscera.
Incorrect
Choices:
B: Applying an abdominal binder snugly can increase pressure on the wound site, potentially worsening the separation and protrusion.
C: Using sterile gloves to apply pressure may further damage the exposed tissues and should be avoided.
E: Offering a warm beverage is not appropriate in this emergency situation and does not address the immediate need for wound management.
Question 5 of 5
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, C. A postop wound infection typically presents with increased incisional pain (
A), fever & chills (
B), and reddened wound edges (
C). Pain may be due to inflammation caused by the infection. Fever and chills are systemic signs of infection. Reddened wound edges indicate inflammation and possible infection spreading.
Choices D and E are incorrect as increased serosanguineous drainage (
D) may be seen in the normal healing process, and a decrease in thirst (E) is not typically associated with wound infection.