ATI RN
ATI Fundamentals Final Exam Questions
Extract:
Question 1 of 5
During an assessment,a client who is not very talkative appears pale diaphoretic,and restless in the bed and says "leave me alone." Which subjective data should the nurse document?
Correct Answer: C
Rationale: Subjective data is information reported by the client. The statement "leave me alone" is subjective reflecting the client's feelings and emotions and should be documented. Other options are objective observations or unrelated interventions.
Question 2 of 5
The nurse is offering free occult blood screenings at a community health fair. Which level of practice is the nurse providing?
Correct Answer: A
Rationale: Offering free occult blood screenings at a community health fair is an illness prevention service aimed at detecting early signs of colorectal cancer to prevent disease onset through early intervention and treatment. Types of Fecal Occult Blood Tests
Question 3 of 5
The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?
Correct Answer: D
Rationale: The nurse should immediately report a respiratory rate of 8 to the physician. A normal adult respiratory rate is 12–20 breaths per minute and a rate of 8 indicates respiratory depression a potential side effect of epidural pain medication (e.g. opioids). This is a critical finding requiring prompt intervention to prevent respiratory failure. Blood pressure of 120/80 (
A) pain rating of 4 (
B) and pulse rate of 80 (
C) are within normal or acceptable ranges and do not require immediate reporting.
Question 4 of 5
The client who has sleep apnoea reports falling asleep while driving,almost being involved in an accident and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?
Correct Answer: C
Rationale: The priority nursing diagnosis for this client is Risk for injury related to somnambulism. Sleepwalking (somnambulism) and falling asleep while driving pose immediate safety risks as the client could harm themselves or others during these episodes. Prioritizing safety aligns with Maslow’s hierarchy where physiological and safety needs take precedence. While impaired gas exchange (
D) is relevant to sleep apnea the immediate risk of injury from sleepwalking and daytime sleepiness is more urgent. Disturbed sleep pattern (
A) and thought processes (
B) are less immediate concerns.
Question 5 of 5
A nurse is taking care of an adult client who throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying?
Correct Answer: D
Rationale: The adult client is displaying regression a defense mechanism where an individual reverts to an earlier stage of development in response to stress or conflict. Throwing a temper tantrum a behavior typical of young children indicates regression to a less mature coping mechanism when the client does not get his way. Repression (
A) involves suppressing memories rationalization (
B) justifies behavior and reaction formation (
C) involves acting opposite to true feelings none of which fit the scenario.