ATI RN
ATI Fundamentals 2023 Retake Questions
Extract:
Question 1 of 5
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
Correct Answer: D
Rationale: The correct answer is D: Strike a flat hand covering the costovertebral angle (CV
A). This method is known as CVA tenderness test and is used to assess for flank tenderness specifically related to kidney inflammation like pyelonephritis. By striking the CVA, the nurse can elicit pain or tenderness in the affected kidney area. Percussing between the iliac crest and ribs (
A) is used to assess for liver size. Pushing fingers upward into the intercostal spaces (
B) is done to assess for splenomegaly. Palpating along the lumbar vertebral column (
C) is not specific for flank tenderness related to pyelonephritis.
Question 2 of 5
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Help the client lie on the floor. This is the first action the nurse should take during a seizure to prevent injury. Lying on the floor reduces the risk of falling and hitting objects. Moving items away (
A) is important but only after ensuring client safety. Turning the client onto their side (
C) is done after the seizure to maintain an open airway. Loosening clothing (
D) can be done after ensuring the client is safe on the floor.
Question 3 of 5
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
Correct Answer: D
Rationale: The correct answer is D: Strike a flat hand covering the costovertebral angle (CV
A). This method is known as CVA tenderness test and is used to assess for flank tenderness specifically related to kidney inflammation like pyelonephritis. By striking the CVA, the nurse can elicit pain or tenderness in the affected kidney area. Percussing between the iliac crest and ribs (
A) is used to assess for liver size. Pushing fingers upward into the intercostal spaces (
B) is done to assess for splenomegaly. Palpating along the lumbar vertebral column (
C) is not specific for flank tenderness related to pyelonephritis.
Question 4 of 5
A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide the client with a night light. This is important for fall prevention as it helps the client see clearly at night, reducing the risk of tripping or falling in the dark. Night lights can improve visibility and safety without disrupting sleep.
Choice B could potentially restrict the client's movement and increase the risk of entrapment.
Choice C does not directly address fall prevention.
Choice D focuses on room temperature, which is not directly related to fall risk.
Question 5 of 5
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
Correct Answer: A
Rationale: The correct answer is A: Three-point gait. This gait is appropriate for a client who can only bear weight on one leg as it involves bearing weight on one leg while advancing both crutches forward, then advancing the unaffected leg forward. This gait provides maximum stability and support for the client.
B: Two-point alternating gait involves bearing weight on both legs alternately, which may not be suitable for a client who can only bear weight on one leg.
C: Four-point alternating gait involves bearing weight on both legs and crutches in a coordinated manner, which may be too complex for a client with limited weight-bearing ability.
D: Swing-through gait involves swinging both legs forward simultaneously, which is not suitable for a client who can only bear weight on one leg.
Therefore, the three-point gait is the most appropriate choice for this client.