ATI RN
Leadership ATI Proctored
1. During a physical assessment of adult clients, which of the following techniques should the nurse use?
- A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client experiencing pain.
- B. Palpate the client's abdomen before auscultating bowel sounds.
- C. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
- D. Obtain an apical heart rate by auscultating at the third intercostal space to the left of the sternum.
Correct answer: B
Rationale: When performing a physical assessment, it is essential to palpate the client's abdomen before auscultating bowel sounds. This sequence helps prevent altering bowel sound results due to the pressure applied during palpation. Choice A is incorrect because the FLACC pain rating scale is typically used for nonverbal or pediatric clients, not adults. Choice C is incorrect because the bladder of the blood pressure cuff should surround about 80% of the client's arm circumference, not the bladder of the cuff itself. Choice D is incorrect because to obtain an apical heart rate, auscultation should be done at the fifth intercostal space at the midclavicular line, not at the third intercostal space to the left of the sternum.
2. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
- A. The passage of flatus
- B. Absent bowel sounds
- C. The client’s ability to tolerate food
- D. Bloody drainage from the colostomy
Correct answer: A
Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It’s a positive sign that the bowel is recovering from the surgery and starting to work as intended.
3. A nurse is evaluating the effectiveness of teaching regarding care of a child with minimal change nephrotic syndrome (MCNS) that is in remission after administration of prednisone. The nurse realizes further teaching is required if the parents state what?
- A. We will keep our child away from anyone who is ill.
- B. We will be sure to administer the prednisone as ordered.
- C. We will encourage our child to eat a balanced diet, but we will watch his salt intake.
- D. We understand our child will not be able to attend school, so we will arrange for home schooling.
Correct answer: D
Rationale: Children with MCNS in remission can usually return to school. Home schooling may be necessary only if there are complications. The other options show an understanding of proper care during remission.
4. The anatomy of a body part is closely related to its physiology.
- A. True
- B. False
- C. Not Sure
- D. None of the above
Correct answer: A
Rationale: The statement is true. Anatomy and physiology are interconnected fields. Anatomy focuses on the structure of body parts, while physiology deals with the functions of those parts. Understanding the structure (anatomy) of a body part is crucial in comprehending how it functions (physiology). This interrelation is essential for healthcare professionals to diagnose and treat medical conditions effectively. Choice B is incorrect because anatomy and physiology are indeed closely related. Choice C is incorrect as well because the relationship between anatomy and physiology is a fundamental concept in the study of the human body. Choice D is incorrect as the statement is true.
5. When a patient with major depressive disorder is prescribed escitalopram, what potential side effect should the healthcare provider educate the patient about?
- A. Weight gain
- B. Insomnia
- C. Diarrhea
- D. Hypertension
Correct answer: B
Rationale: The correct answer is B: Insomnia. Escitalopram, a selective serotonin reuptake inhibitor (SSRI), commonly causes insomnia as a side effect. Patients should be informed about the possibility of experiencing difficulty falling or staying asleep when starting this medication. Choices A, C, and D are incorrect because weight gain, diarrhea, and hypertension are not typically associated with escitalopram use.
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