ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is alert and oriented.The client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities are performed once each day.On Day 5, the client’s feet are warm, pedal pulses are 2+ bilaterally, plantar flexion contractures are noted bilaterally, and the left heel has a 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, with skin intact.
Question 1 of 5
Which findings require intervention by the nurse?
Correct Answer: A,B,C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Passive range-of-motion exercises to lower extremities performed once each day are important to prevent contractures and maintain joint mobility in immobile patients.
B: Left heel with nonblanchable erythema indicates a pressure injury or early sign of skin breakdown, requiring intervention to prevent further damage.
C: Plantar flexion contractures can lead to foot drop and impair mobility, so early intervention is necessary to prevent complications.
Summary:
D: Pedal pulses 2+ bilaterally indicate good circulation, which does not require immediate intervention.
E, F, G: Insufficient information provided to determine if these findings require immediate intervention.
Extract:
A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present.
Question 2 of 5
Which observation should the nurse identify as a potential sign of elder abuse?
Correct Answer: C
Rationale: The correct answer is C because a caregiver insisting on staying in the room can be a potential sign of elder abuse, as it may indicate controlling behavior or a desire to monitor interactions. The other choices are less indicative of abuse: A could be related to mobility issues, B may reflect personal hygiene preferences, and D is a common legal arrangement for managing finances.
Extract:
Question 3 of 5
A patient reports abdominal pain.An abdominal x-ray indicates a large amount of fecal material throughout the colon, but no evidence of gastrointestinal obstruction is observed.Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Administer a cleansing enema. This is the appropriate action because the large amount of fecal material in the colon indicates constipation. Administering a cleansing enema can help relieve the constipation by softening and loosening the stool, making it easier for the patient to pass. This intervention is non-invasive and can be effective in resolving the patient's abdominal pain.
Choice A is incorrect because the patient already has fecal material throughout the colon, so positioning alone may not be sufficient to alleviate the symptoms.
Choice B is incorrect as a chest x-ray would not provide relevant information for the patient's abdominal pain.
Choice D is incorrect because a manual digital examination is not indicated without further assessment or suspicion of a specific rectal issue.
Question 4 of 5
A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?
Correct Answer: B
Rationale: The correct answer is B: Breath sounds. This is the priority because it provides crucial information about the client's respiratory status and the effectiveness of treatment for pneumonia. Abnormal breath sounds could indicate worsening respiratory distress or pneumonia complications. Providing this information helps the oncoming nurse assess the client's current condition and make timely interventions. The other choices are not as critical: A - Admitting diagnosis is important but does not provide immediate information on the client's current status; C - Body temperature is relevant but may not indicate the severity of pneumonia; D - Diagnostic test results are important but may not provide real-time data on the client's respiratory status.
Extract:
Vital Signs (Updated)
• 0700 hrs:
o Blood Pressure (BP): 138/72 mm Hg
o Heart rate: 80/min
o Respirations: 22/min
o Temperature: 38.3°C (101.1°F)
o Oxygen saturation: 90% on room air
• 1100 hrs:
o Blood Pressure (BP): 132/68 mm Hg
o Heart rate: 92/min
o Respirations: 24/min
o Temperature: 39.0°C (102.2°F)
o Oxygen saturation: 88% on room air
• 1500 hrs:
o Blood Pressure (BP): 126/64 mm Hg
o Heart rate: 100/min
o Respirations: 26/min
o Temperature: 39.5°C (103.1°F)
o Oxygen saturation: 86% on room air
Nurses' Notes
• 0700 hrs:
o The client is alert but appears fatigued. Complaints of increased shortness of breath over the past 24 hours. The client has a productive cough with thick, yellow sputum. The client reports feeling increasingly weak and dizzy. Mild confusion is noted, with difficulty maintaining focus during the assessment. The client is diaphoretic and has been experiencing chills intermittently. The skin appears flushed and warm to the touch.
• 1100 hrs:
o The client is visibly distressed and reports worsening dyspnea. The cough is now accompanied by greenish, foul- smelling sputum. The client exhibits increased confusion and disorientation. The skin is cool and clammy, with noticeable pallor. Respiratory effort is labored, with audible wheezing and crackles upon auscultation. The client reports persistent nausea and decreased appetite. There is a noticeable increase in fatigue and lethargy.
• 1500 hrs:
o The client is significantly drowsy and difficult to arouse. Respiratory distress is evident, with use of accessory muscles for breathing. The sputum is now blood-tinged and the cough is frequent and severe. The skin is very pale, with a bluish tinge noted around the lips. The client shows signs of hypotension and rapid pulse. There is an overall decline in mental status, with severe confusion and disorientation. The client complains of severe weakness and generalized body aches.
Medical History
• Diabetes mellitus, well-managed with medication
• Chronic obstructive pulmonary disease (COPD)
• History of hypertension
• No known drug allergies
• Recent travel to an area with known respiratory infections
Diagnostic Results
• 0700 hrs:
o Chest X-ray: Mild infiltrates in the lower lobes
o CBC: Elevated white blood cell count (WBC) 12,000/µL
• 1100 hrs:
o Chest X-ray: Progression of infiltrates with more pronounced consolidation
o CBC: Further elevated white blood cell count (WBC) 15,000/µL; Elevated C-reactive protein (CRP)
• 1500 hrs:
o Chest X-ray: Extensive consolidation with possible pleural effusion
o CBC: High white blood cell count (WBC) 18,000/µL; Elevated CRP; Low hemoglobin (Hb)
Provider's Prescriptions
• 0700 hrs:
o Antibiotic therapy initiated: Levofloxacin 500 mg IV every 24 hours
o Oxygen therapy: 2 L/min via nasal cannula
• 1100 hrs:
o Increased oxygen therapy to 4 L/min via nasal cannula
o Addition of nebulized bronchodilators
• 1500 hrs:
o Oxygen therapy increased to 6 L/min via non-rebreather mask
o Initiation of intravenous corticosteroids
Question 5 of 5
A 60-year-old male client is admitted to the medical-surgical unit. The client is experiencing a worsening of symptoms over the last 24 hours. The client's initial presentation was similar to previous days, but his condition has deteriorated.Exhibits:Based on the evolution of the client’s condition and the provided exhibits, select all that apply. Which of the following actions should the nurse include in the client's care plan?
Correct Answer: B,C,D,E,F
Rationale: The correct answer includes preparing for possible intubation and mechanical ventilation (
B) because the client is experiencing a worsening of symptoms, indicating respiratory distress. Monitoring blood glucose levels frequently (
C) is essential as stress can cause fluctuations in blood sugar levels. Administering IV antibiotics as prescribed (
D) is crucial to treat any infection that may be contributing to the deterioration. Ensuring strict hand hygiene (E) helps prevent the spread of infection. Increasing fluid intake (F) can help thin sputum and ease breathing. Implementing airborne precautions (
A) is not necessary unless specific respiratory infections are suspected. Assisting with chest tube insertion (G) is not indicated based on the information provided.