ATI RN Fundamentals Online Practice 2023 B | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Administer a cleansing enema. This is the appropriate action because the large amount of fecal material in the colon indicates constipation. Administering a cleansing enema can help relieve the constipation by softening and loosening the stool, making it easier for the patient to pass. This intervention is non-invasive and can be effective in resolving the patient's abdominal pain.


Choice A is incorrect because the patient already has fecal material throughout the colon, so positioning alone may not be sufficient to alleviate the symptoms.
Choice B is incorrect as a chest x-ray would not provide relevant information for the patient's abdominal pain.
Choice D is incorrect because a manual digital examination is not indicated without further assessment or suspicion of a specific rectal issue.

Correct Answer: D

Rationale: The correct answer is D: "I will wear a face mask when leaving my hospital room." This statement shows understanding of the need to prevent the spread of infection by wearing a face mask, a key aspect of protective isolation precautions.
Choice A is incorrect as shower frequency doesn't relate to isolation precautions.
Choice B is incorrect as it doesn't address infection control.
Choice C is incorrect because taking a plane could expose others to potential infection.

Correct Answer: C

Rationale: The correct answer is C: Have the patient stand with their arms at their sides and their feet together. During a Romberg test, the patient is asked to stand with their feet together and arms at their sides to assess their ability to maintain balance with eyes closed. This position challenges the patient's proprioception and vestibular system. This test helps to evaluate the patient's sensory and motor systems, specifically the cerebellum and proprioceptive pathways.

Incorrect choices:
A:
Touch the patient's face with a cotton ball - This does not assess balance or proprioception.
B: Apply a vibrating tuning fork to the patient's forehead - This tests for cranial nerve function, not balance.
D: Perform direct percussion over the area of the kidneys - This is unrelated to the Romberg test and assesses kidney function, not balance.

Correct Answer: C

Rationale: The correct answer is C: Tachycardia. Tachycardia refers to an abnormally rapid heart rate. In a patient exhibiting symptoms, this could indicate a fast heartbeat, which is a common sign of various medical conditions such as anxiety, heart disease, or hyperthyroidism. Hypertension (
A) is high blood pressure, not related to heart rate. Hypotension (
B) is low blood pressure. Bradycardia (
D) is a slow heart rate. Since the patient exhibits symptoms, tachycardia (
C) is the most relevant choice to describe the rapid heart rate.

Correct Answer: C

Rationale: The most likely diagnosis is pneumonia (
Choice
C) because the client's chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Lung hyperinflation can result from air trapping in the lungs, commonly seen in pneumonia. Left upper lobe pneumonia typically presents with symptoms such as cough, fever, and chest pain. Tuberculosis (
Choice
A) would typically present with different radiographic findings like cavitary lesions. Bronchitis (
Choice
B) presents with inflammation of the bronchial tubes, not hyperinflation. Asthma (
Choice
D) would show signs of reversible airway obstruction, not hyperinflation.