ATI RN
ATI RN Fundamentals Exam 6 Questions
Extract:
Question 1 of 5
A nurse is observing a client who has right-sided weakness ambulate using a cane. Which of the following actions by the client should alert the nurse that further teaching is necessary?
Correct Answer: A
Rationale: Holding the cane on the affected side is a correct technique to provide support. Keeping two points of support on the ground is a proper technique for stability. Advancing the cane before moving the unaffected leg is incorrect and may lead to instability and increased risk of falls. Supporting weight on both legs while moving the cane forward is a correct technique for stability during ambulation.
Question 2 of 5
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1200 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero is applicable. Do not use a trailing zero.)
Correct Answer: 150
Rationale: The formula for the infusion rate is: (volume in mL / time in hours) x drop factor in gtts/mL = infusion rate in gtts/min. The drop factor is usually given on the IV tubing package and varies depending on the type of tubing used. For this question we can assume a drop factor of 15 gtts/mL which is common for macrodrip tubing. Plugging in the numbers we get: (1200 mL / 8 hr) x 15 gtts/mL = 2250 gtts/hr.
To convert from gtts/hr to mL/hr we divide by the drop factor: 2250 gtts/hr / 15 gtts/mL = 150 mL/hr.
Therefore the nurse should set the IV pump to deliver 150 mL/hr.
Question 3 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 4 of 5
A nurse is caring for a client who has been diagnosed with breast cancer. After months of treatment the client refuses to undergo further radiation therapy. Which of the following actions by the nurse is appropriate?
Correct Answer: A
Rationale: Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare. Referring the client to a counselor can be appropriate but the primary response should be to support the client's decision. Encouraging the client not to give up may not be appropriate if the client has made a well-considered decision to refuse further treatment. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.
Question 5 of 5
A nurse is teaching a client proper use of an albuterol inhaler during acute asthma exacerbations. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: D
Rationale: Tilted head forward is not necessary during inhaler use. The client should maintain an upright position. Shaking the inhaler before use is correct to ensure proper dispersion of the medication. Rinsing the mouth out before using the inhaler is not necessary for proper technique. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.