ATI RN
ATI Nurse 142 Final Questions
Extract:
Question 1 of 5
The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates the pain as a 7 out of 10 (0 is no pain and 10 is the worst pain possible). This client is moving around easily and is eating well, but has asked for pain medication. Which action by the nurse is most appropriate?
Correct Answer: B
Rationale: Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In general, withholding pain medication for a client in pain is not an appropriate action. Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration. It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim.
Question 2 of 5
When assessing the breast, the nurse would teach the patient to palpate which of the following areas?
Correct Answer: A,B,C
Rationale: The nurse should teach the patient to palpate all four quadrants of the breast (upper outer, lower inner, upper inner) and the tail of Spence, the extension of breast tissue into the axilla. This ensures a comprehensive self-examination to detect any abnormalities.
Question 3 of 5
Child maltreatment, sibling violence, bullying, elder abuse, hate crimes and war/combat violence are types of?
Correct Answer: D
Rationale: Human violence, also referred to as interpersonal violence, encompasses various forms of violence between individuals, including child maltreatment, sibling violence, bullying, elder abuse, hate crimes, and war/combat violence. These involve physical, sexual, or psychological harm and have significant consequences for victims and society.
Question 4 of 5
When assessing the lymph nodes, the nurse should: (select all that apply)
Correct Answer: B,C,D
Rationale: When assessing lymph nodes, the nurse should evaluate mobility, size, shape, and assess bilaterally to compare both sides for abnormalities. Unilateral assessment is not recommended as it may miss important findings on one side.
Question 5 of 5
When assessing the abdomen, the nurse would expect to auscultate which sounds?
Correct Answer: A
Rationale: When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute. Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta. Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs. Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment.