ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice
A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice
C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice
D) is not as proactive as addressing the potential pain issue immediately.
Question 2 of 5
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
Correct Answer: D
Rationale: The correct answer is D because a contaminated specimen can lead to false results. The client should be instructed to avoid contaminating the specimen with urine, water, or toilet bowl cleaners.
Choice A is incorrect because protein intake does not affect the test.
Choice B is incorrect as multiple stool specimens are usually required.
Choice C is incorrect as a blue color change indicates a positive test, not red.
Question 3 of 5
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (
A) and rice pudding & ripe bananas (
C) are low in fiber and may worsen constipation. Roast chicken & white rice (
D) lack sufficient fiber to alleviate constipation.
Question 4 of 5
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (
B) due to decreased blood volume, fever (
C) as a result of dehydration and infection, and poor skin turgor (
D) due to decreased tissue hydration. Bradycardia (
A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
Question 5 of 5
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.
Correct Answer: A, B, C
Rationale: The correct steps for administering a cleansing enema are to warm the enema prior to instillation to prevent discomfort, position the client on the left side with the right leg flexed forward to facilitate the flow of the solution, and lubricate the rectal tube or nozzle to ease insertion. Warming the enema helps relax the colon, the left side position helps the solution flow toward the rectum, and lubrication minimizes discomfort and potential injury. Other choices are incorrect: slowly inserting the rectal tube 2 inches is too shallow, hanging the enema container 24 inches above the client's anus may be too high causing a rapid flow and potential injury.