ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, 'I don't want to take that med. I do not want one more pill.' Which of the following responses by the nurse is appropriate in this situation?
Correct Answer: D
Rationale:
Correct
Answer: D. Tell me your concerns with taking this med.
Rationale: This response demonstrates therapeutic communication by acknowledging the client's feelings and encourages them to express their concerns. It shows empathy and respect for the client's autonomy in decision-making. By understanding the client's reasons for not wanting to take the medication, the nurse can address any misconceptions, provide education, and potentially find alternative solutions. This approach fosters trust and collaboration between the nurse and the client.
Incorrect choices:
A: This response is dismissive of the client's feelings and does not address the underlying concerns.
B: This response does not address the client's reluctance and may come off as insensitive.
C: This response avoids the issue at hand and does not promote open communication.
Question 2 of 5
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
Correct Answer: A,B,E
Rationale:
Correct
Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect
Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
Question 3 of 5
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (
Choice
A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (
Choice
C) is important but not the priority in this case. Obtaining arterial blood gases (
Choice
D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
Question 4 of 5
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
Correct Answer: A, D, E
Rationale:
Correct
Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect
Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
Question 5 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
Correct Answer: A, B, C
Rationale: The correct actions are A, B, and C.
A) Applying the oxygen source loosely if the SPO2 decreases during the procedure ensures adequate oxygenation.
B) Using surgical asepsis to remove and clean the inner cannula prevents infection.
C) Cleaning the outer surfaces in a circular motion from the stoma site outward helps prevent contamination. Other options are incorrect because:
D) Replacing the tracheostomy ties with new ties is not necessary each time. E) Cutting a slit in gauze squares is not a standard practice for tracheostomy care.