ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 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 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: The correct answers are A, B, and E. Restlessness is an early indication of hypoxemia because the body is trying to compensate for decreased oxygen levels. Tachypnea (rapid breathing) is the body's response to hypoxemia to increase oxygen intake. Pallor is a sign of decreased oxygen saturation in the blood. Bradycardia and confusion are not typically early signs of hypoxemia, as the body usually increases heart rate to compensate for low oxygen levels, and confusion is a later sign indicating severe hypoxemia.
Question 3 of 5
A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching?
Correct Answer: B
Rationale: The correct answer is B: "This thing will keep the blood pumping through my leg." This statement indicates understanding because sequential compression devices help prevent blood clots by promoting blood flow in the legs.
Choice A is incorrect as the device does not prevent skin sores.
Choice C is incorrect because the device does not prevent muscle weakness.
Choice D is incorrect as the device does not specifically target joint health.
Question 4 of 5
A nurse is reviewing the CDC's immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all.
Correct Answer: A, B, C
Rationale: The correct answer includes HPV, MMR, and Varicella because these vaccines are recommended for young adults by the CDC. HPV vaccine helps prevent certain cancers, MMR protects against highly contagious diseases, and Varicella prevents chickenpox. The other choices are incorrect: Haemophilus influenzae type b is typically given to children under 5, and Polio is usually administered in childhood. It's important for the nurse to discuss vaccines based on the client's age and health status.
Question 5 of 5
A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by:
Correct Answer: C
Rationale: The correct answer is C because offering the client a pain scale to measure his pain allows for a standardized and quantifiable assessment of pain intensity. Pain scales such as the Numeric Rating Scale or Visual Analog Scale help the client express their pain level, facilitating better communication between the client and the nurse. This approach ensures a more objective evaluation of pain, enabling appropriate pain management interventions to be implemented.
As for the other choices:
A: Asking what precipitates the pain focuses on triggers rather than intensity.
B: Questioning about the location of pain is important but does not directly assess pain intensity.
D: Using open-ended questions may provide valuable information but does not offer a standardized measure of pain.
In summary, the other choices do not provide a direct and standardized assessment of pain intensity, making them less effective in this scenario.