ATI RN
ATI Fundamentals Proctored Exam 2024
1. Which natural body defense plays an active role in preventing infection?
- A. Yawning
- B. Body hair
- C. Hiccupping
- D. Rapid eye movements
Correct answer: B
Rationale: Body hair plays an active role in preventing infection by acting as a filter to block pathogens. It helps to prevent harmful substances from entering the body through the skin, providing a physical barrier against potential infections.
2. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?
- A. Immediately do a complete head-to-toe neurological assessment.
- B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
- C. Place a blanket over the feet.
- D. Remove the restraint.
Correct answer: D
Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.
3. A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?
- A. Document the color of the patient's palms and face during each visit.
- B. Follow the patient's erythrocyte sedimentation rate over time.
- C. Document the patient's response to erythropoietin injections.
- D. Follow the trends of the patient's hematocrit.
Correct answer: D
Rationale: The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain below 45%. Hematocrit levels are a key indicator in assessing the progression of the disease. Choices A, B, and C are not the most appropriate methods for gauging the course of polycythemia vera. Monitoring the color of the patient's palms and face, or their response to erythropoietin injections, may not provide an accurate reflection of the disease's progression. Similarly, while erythrocyte sedimentation rate can be affected in polycythemia vera, it is not the primary marker for monitoring the disease's course.
4. A client with rheumatoid arthritis is experiencing morning stiffness. Which of the following actions should the nurse take?
- A. Encourage the client to avoid physical activity in the morning.
- B. Encourage the client to take NSAIDs before bedtime.
- C. Apply cold packs to the affected joints in the morning.
- D. Perform passive range-of-motion exercises before getting out of bed.
Correct answer: C
Rationale: The correct action the nurse should take is to apply cold packs to the affected joints in the morning. Rheumatoid arthritis is characterized by inflammation, and applying cold packs can help reduce inflammation and stiffness in the joints. Encouraging the client to avoid physical activity in the morning (Choice A) may worsen stiffness, as movement is beneficial for joint mobility. While NSAIDs (Choice B) can help with pain and inflammation, applying cold packs directly to the affected joints is more targeted and effective. Performing passive range-of-motion exercises (Choice D) can be helpful, but applying cold packs is the priority for reducing inflammation and stiffness.
5. What is an advantage of the ventrogluteal muscle as an injection site in young children?
- A. Easily accessible from many directions
- B. Free of significant nerves and vascular structures
- C. Can be used until the child reaches a weight of 9 kg (20 lb)
- D. Increased subcutaneous fat, which provides sustained drug absorption
Correct answer: B
Rationale: The ventrogluteal site is free of significant nerves and vascular structures, making it a safer choice for intramuscular injections in young children compared to other sites that may be more prone to complications.