ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
Your patient drunk 150 mL of Ice Tea. How many ounces is this?
Correct Answer: 5
Rationale: Solution: 1 ounce = 30 mL, so 150 mL ÷ 30 mL/oz = 5 oz. Answer: 5 ounces.
Question 2 of 5
A nurse on the telemetry(cardiac unit) is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 pain scale. The nurse administers 1 nitroglycerin (sublingual). After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions Should the nurse take?
Correct Answer: C
Rationale: Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.
Question 3 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shearing. Which score will the nurse document for this patient?
Correct Answer: D
Rationale: Sensory perception: Slightly limited (score of 3). Moisture: Rarely moist (score of 4). Activity: Walks occasionally (score of 3). Mobility: Slightly limited (score of 3). Nutrition: Excellent intake (score of 4). Friction and shear: No apparent problem (score of 3). Adding these scores together: 3 + 4 + 3 + 3 + 4 + 3 = 20.
Therefore, the nurse should document a score of 20 for this patient.
Question 4 of 5
A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?
Correct Answer: D
Rationale: Inhale slowly and evenly through her nose: The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively. Hold her breath for at least 10 seconds: Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort. Place her hands on the sides of her rib cage: While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding. Exhale forcefully through the nose: Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.
Question 5 of 5
A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions?
Correct Answer: C
Rationale: Uses critical thinking for the highest level of quality nursing care: Professional standards provide guidelines for best practices, ensuring nurses apply critical thinking and clinical judgment to improve patient outcomes. Utilizing evidence-based practice based on nurses' needs: Professional standards focus on patient-centered care, not the nurse's needs. Evidence-based practice should prioritize patient safety and effectiveness. Establishes minimal passing standards for testing: While professional standards guide nursing education and testing, their primary role is to guide clinical decision-making for patient care. Bypasses the patient's feelings to promote ethical standards: Ethical nursing practice includes patient advocacy, not bypassing patient emotions or concerns.