ATI RN
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ATI N 144 Exam 1 Fundamental Concepts for Nursing Practice Questions
Extract:
Question
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1 of 5
A nurse on a medical-surgical unit knows that for clients with a BMI greater than or equal to 30,it is important to:
Correct Answer: B
Rationale: Using an appropriately sized blood pressure cuff is critical for clients with a BMI ≥ 30 to ensure accurate readings. Supine positioning can impair breathing in obese clients. Obesity does not indicate malnutrition/underweight. Frail bones are associated with osteoporosis not obesity though mobility issues may warrant fall precautions.
Question 2 of 5
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?
Correct Answer: A
Rationale: Assessment is the first and most important phase of the nursing process as it involves collecting and analyzing data about the patient’s health status needs and preferences. The nurse should have assessed the patient’s blood pressure before administering the antihypertensive medication as it could have been contraindicated or required a dosage adjustment. By failing to do so the nurse put the patient at risk of hypotension and its complications.
Question 3 of 5
A nurse is collecting data from a client who has open-angle glaucoma. Which of the following symptoms should the nurse expect the patient to report?
Correct Answer: A
Rationale: Gradual loss of peripheral vision is characteristic of open-angle glaucoma due to blocked drainage angles increasing intraocular pressure and damaging the optic nerve. Central vision loss is typical of macular degeneration sudden headache and nausea indicate acute angle-closure glaucoma and cloudy vision suggests cataracts.
Question 4 of 5
A diabetic client states he feels depressed,is complaining of chest pain and has an open wound. Which of these complaints would require an immediate focused assessment?
Correct Answer: D
Rationale: Chest pain may indicate a life-threatening condition like a heart attack requiring immediate assessment to evaluate cardiac and respiratory function. Open wounds and depression are concerns but less urgent unless severe. Diabetes is a chronic condition not requiring immediate focus unless in crisis.
Question 5 of 5
The RN has completed an assessment on a client. What should the nurse do next?
Correct Answer: C
Rationale: Analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns relationships and trends in the assessment data and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient’s problems needs strengths and risks. Reassessment occurs later interventions and SMART goals follow diagnosis which requires analysis first.