ATI RN
ATI N 144 Exam 1 Fundamental Concepts for Nursing Practice Questions
Extract:
Question 1 of 5
The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment,the nurse notes crackles shortness of breath and jugular vein distention. Based on this data which complication of IV fluid therapy does the nurse anticipate?
Correct Answer: B
Rationale: Fluid volume excess is a condition in which the body retains more fluid than it needs resulting in edema hypertension and heart failure. It is a potential complication of IV fluid therapy especially in older adults who have reduced renal function and cardiac output. The nurse's assessment findings of crackles shortness of breath and jugular vein distention are indicative of fluid overload and pulmonary congestion. Fluid volume deficit would present with dehydration and hypotension which are not indicated here. Speed shock is related to rapid medication administration not fluid therapy. Pulmonary embolism involves a blockage in pulmonary arteries typically with symptoms like chest pain and hemoptysis not fluid overload signs.
Question 2 of 5
A nurse is caring for a client who states,I did not take my medication because my partner forgot to remind me. The nurse should identify that the client is demonstrating which of the following defense mechanisms?
Correct Answer: D
Rationale: Rationalization involves using logical explanations to justify actions as the client blames their partner for forgetting to remind them avoiding personal responsibility. Identification adopts others’ behaviors denial refuses reality and displacement redirects feelings none of which fit this scenario.
Question 3 of 5
A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?
Correct Answer: A
Rationale: Stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place and avoid applying any pressure or movement to the eye. Applying anesthetic drops removing the object or using ointment could worsen the injury and are not initial priorities.
Question 4 of 5
Identify which client could be considered to be in a state of wellness?
Correct Answer: C
Rationale: A hospice client who is comfortable and at peace with dying is in a state of wellness. Wellness is not only the absence of disease but also the presence of positive health behaviors and attitudes. The client’s acceptance and comfort reflect emotional and spiritual well-being aligning with wellness. The other options involve ignoring health risks emotional distress or unhealthy behaviors which do not reflect wellness.
Question 5 of 5
A client has chronic back pain from a work-related injury that occurred 5 years ago. Which patient goal meets the SMART criteria?
Correct Answer: D
Rationale: The client will engage in desired activities without the pain level increasing above a pain scale level of 3 out of 10 within one month is a SMART goal. This goal is specific (desired activities pain level) measurable (pain scale) achievable (pain threshold of 3) relevant (enhances quality of life) and time-bound (within one month). Other options lack specificity measurability or time boundaries.