ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
Correct Answer:
Rationale:
Correct Answer: D
Rationale:
1. Crackles are typically heard in the lower lung fields where fluid accumulates in pneumonia.
2. Anterior chest wall location D corresponds to the lower lung fields where crackles are most likely to be heard.
3. By auscultating at location D, the nurse can accurately assess for crackles in the affected area.
Summary:
- A, B, and C are incorrect as they are higher on the chest wall and not where crackles are typically heard in pneumonia.
- E, F, and G are not valid choices as they do not correspond to any specific lung fields for auscultation in pneumonia.
Question 2 of 5
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement at a consistent time, aiding in establishing a regular bowel routine for the client following a spinal cord injury. The suppository acts as a stimulant to facilitate bowel evacuation.
Choices A, B, and D are incorrect. A diet high in refined grains may lead to constipation due to lack of fiber. Providing a cold drink before defecation does not directly impact bowel training. Restricting fluid intake to 1,500 mL per day is not advisable as it may lead to dehydration and worsen constipation.
Question 3 of 5
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Correct Answer: A
Rationale: The correct answer is A because removing the cap and placing it sterile-side up on a clean surface helps maintain the sterility of the solution. Placing the cap sterile-side up prevents contamination of the inside of the cap. This action ensures that the contents of the bottle remain sterile while allowing easy access to the solution during the procedure.
In contrast, option B is incorrect because placing sterile gauze over spilled solution within the sterile field may introduce non-sterile material into the field. Option C is incorrect as holding the bottle in the center of the sterile field may increase the risk of accidental contamination. Option D is incorrect because holding the irrigation solution bottle with the label facing away from the palm of the hand does not ensure the sterility of the solution.
Question 4 of 5
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate during postmortem care to provide a peaceful appearance for the family viewing. By gently closing the deceased client's eyes, the nurse can create a more natural and serene expression, helping the family to remember their loved one in a dignified manner. It is essential to maintain the client's dignity and respect during this sensitive process.
Crossing the client's arms across their chest (
A) is a common misconception but not necessary for postmortem care. Placing the client in a high-Fowler's position (
C) is not appropriate as it is used for living clients for respiratory support. Removing the client's dentures (
D) should not be done unless requested by the family or healthcare provider.
Question 5 of 5
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. A constant P-R interval of 0.35 seconds indicates a prolonged conduction time between the atria and ventricles. In first-degree AV block, there is a delay in the conduction through the AV node, resulting in a prolonged P-R interval. This dysrhythmia is characterized by a consistent delay without dropped beats.
Choice B (Complete heart block) would present with a variable P-R interval and complete dissociation between atrial and ventricular activity.
Choice C (Premature atrial complexes) are early electrical impulses originating in the atria, not involving the AV node.
Choice D (Atrial fibrillation) would show irregular and chaotic atrial activity without a consistent P-R interval.