ATI RN
ATI Nurse 142 Final Questions
Extract:
Question 1 of 5
The nurse noted which of the following about the patient's skin during her monitoring assessment. (Select all that apply)
Correct Answer: B,C
Rationale: Skin assessment includes evaluating temperature (to detect illness or injury) and turgor (to assess hydration). Tachypnea is a respiratory rate finding, and tympany is a percussion sound, not related to skin assessment.
Question 2 of 5
The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?
Correct Answer: B
Rationale: Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips.
Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.
Question 3 of 5
The nurse is assessing the patient's ear. The correct procedure for straightening the ear canal of an adult is to pull the pinna…
Correct Answer: B
Rationale: For an adult, the correct method to straighten the ear canal during examination is to pull the pinna up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane and inner structures. Pulling down and back is appropriate for children under 3, while the other options do not correctly align the canal.
Question 4 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 5 of 5
The nurse is assessing the patient's range of motion. The nurse asks the patient to circumduct his arms. When the patient asks what this means, the nurse explains:
Correct Answer: B
Rationale: Circumduction is a movement that involves the circular rotation of a limb, such as an arm or leg, around a fixed point. When assessing the patient's range of motion, the nurse may ask the patient to perform circumduction of their arms to evaluate their ability to move their arms in a circular motion.