ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and the heel-to-toe walk. The Romberg test evaluates the client's ability to maintain balance with eyes closed, assessing proprioception. The heel-to-toe walk tests balance, coordination, and gait, evaluating the client's ability to walk in a straight line. The Snellen test assesses visual acuity, not balance. Spinal accessory function evaluates shoulder movement, not balance. The Rosenbaum test is used to assess near vision, not balance.
Question 2 of 5
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Report observations to the nurse manager on the unit. This action is crucial for patient safety and the well-being of the drowsy nurse. By reporting to the nurse manager, appropriate steps can be taken to address the issue, such as evaluating the nurse's workload, offering support or counseling, or implementing policies to prevent such incidents in the future.
Choice A is incorrect as simply reminding the nurse may not address the underlying issue.
Choice B is less effective as it may delay necessary intervention.
Choice D is incorrect as patient safety is a collective responsibility. Reporting to the nurse manager is the best course of action to ensure proper handling of the situation.
Question 3 of 5
A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all.
Correct Answer: B, C
Rationale:
Correct Answer: B, C
Rationale:
B: Putting the date and time on all entries is crucial for legal purposes to establish a timeline of events and ensure accuracy in documentation.
C: Documenting objective data and excluding opinions maintains objectivity and prevents subjective biases from influencing the client's record.
Summary:
A: Covering errors with correction fluid is not recommended as it can be perceived as an attempt to conceal mistakes, compromising the integrity of the record.
D: Using excessive abbreviations can lead to misinterpretation and errors in communication, compromising the clarity and accuracy of the record.
E: Waiting until the end of the shift to document can result in important information being forgotten or inaccurately recorded, impacting the quality of care provided.
Question 4 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 5 of 5
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
Correct Answer: B, E
Rationale:
Correct Answer: B, E
Rationale:
1. Applying elastic stockings (
Choice
B) helps promote circulation, reducing stasis in the lower extremities, thus lowering the risk of thrombus formation.
2. Assisting the client to change position often (
Choice E) prevents prolonged immobility, which is a major risk factor for thrombus development.
Incorrect
Choices:
A: Instructing the client not to use the Valsalva maneuver (
Choice
A) is unrelated to thrombus prevention.
C: Reviewing lab values for total protein level (
Choice
C) is important for overall health monitoring, but not specific to thrombus prevention.
D: Placing pillows under the client's knees & lower extremities (
Choice
D) may help with comfort but does not directly reduce thrombus risk.