palpating the midclavicular line is the correct technique for assessing palpating the midclavicular line is the correct technique for assessing
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. Palpating the midclavicular line is the correct technique for assessing

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

2. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?

Correct answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.

3. After surgery, your patient starts to shiver uncontrollably. What nursing intervention would you do first?

Correct answer: Apply warm blankets & continue oxygen as prescribed

Rationale: When a patient starts shivering uncontrollably after surgery, the priority nursing intervention is to apply warm blankets and continue oxygen as prescribed. Shivering can be a sign of hypothermia, and maintaining the patient's body temperature is crucial for their recovery. This intervention helps prevent further heat loss and supports the patient's comfort and safety. While monitoring temperature, paging the doctor, and adjusting the room temperature may be necessary, addressing the immediate need for warmth and oxygen is the priority in this situation.

4. The nurse is planning an educational session for a group of 9-year-olds and their parents aimed at decreasing injuries and accidents among this age group. Which topics should be included in the educational session to accomplish the goal?

Correct answer: C

Rationale: For school-aged children, pedestrian, motor vehicle, and bike safety are critical areas to focus on as accidents involving these are common in this age group. Education about fire safety and toxic substances is also important, but the priority is on preventing accidents in everyday activities. Therefore, choices A, B, and D are not the most relevant for addressing the goal of decreasing injuries and accidents in this age group.

5. An RN knows that sometimes, when working through an ethical dilemma, the decision makers are unable to arrive at a mutually agreed upon decision. Which of the following is a reason why an agreement cannot be reached?

Correct answer: D

Rationale: A patient may make a request that is not possible within the institution. When this occurs, a solution may not be possible within the institution and the patient may need to be transferred to a different institution that may be able to honor the request.

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