ATI RN
ATI Fundamentals Proctored Exam 2024
1. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:
- A. Ineffective airway clearance related to thick, tenacious secretions.
- B. Ineffective airway clearance related to dry, hacking cough.
- C. Ineffective individual coping with COPD.
- D. Pain related to immobilization of affected leg.
Correct answer: A
Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.
2. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?
- A. ''I am allergic to morphine.''
- B. ''I take antacids several times a day.''
- C. ''I had a blood clot in my leg several years ago.''
- D. ''It hurts to take a deep breath.''
Correct answer: ''I take antacids several times a day.''
Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.
3. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?
- A. Arrange for an ethics committee meeting to address the family's concerns.
- B. Support the family's decision and initiate life-sustaining measures.
- C. Complete an incident report.
- D. Encourage the family to contact an attorney.
Correct answer: Arrange for an ethics committee meeting to address the family's concerns.
Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.
4. What is the most common psychogenic disorder among elderly individuals?
- A. Depression
- B. Sleep disturbances (e.g., bizarre dreams)
- C. Inability to concentrate
- D. Decreased appetite
Correct answer: A
Rationale: Depression is the most common psychogenic disorder among elderly individuals. It can manifest as persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyed. Elderly individuals may also experience changes in appetite, sleep disturbances, and difficulty concentrating. Detecting and addressing depression in the elderly is crucial for their overall well-being and quality of life.
5. Prior to a thoracentesis, which of the following actions should the nurse take?
- A. Position the client in an upright position, leaning over the bedside table.
- B. Explain the procedure.
- C. Obtain ABGs.
- D. Administer benzocaine spray.
Correct answer: Position the client in an upright position, leaning over the bedside table.
Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.