ATI RN
ATI Fundamentals Proctored Exam 2024
1. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct answer: C
Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.
2. When a patient asks the nurse what hypersensitivity is, how should the nurse respond? Hypersensitivity is best defined as:
- A. A reduced immune response found in most pathologic states
- B. A normal immune response to an infectious agent
- C. An excessive or inappropriate response of the immune system to a sensitizing antigen
- D. Antigenic desensitization
Correct answer: C
Rationale: Hypersensitivity is correctly defined as an excessive or inappropriate response of the immune system to a sensitizing antigen. This response leads to tissue damage or other clinical manifestations. Choice A is incorrect as hypersensitivity involves an exaggerated, not a reduced, immune response. Choice B is incorrect because hypersensitivity is not a normal immune response to an infectious agent but rather an exaggerated one. Choice D is incorrect as it refers to desensitization, which is the opposite of hypersensitivity.
3. When teaching a client with a new prescription for Sulfasalazine, which instruction should the nurse include?
- A. Expect orange discoloration of urine and skin.
- B. Increase your intake of high-sodium foods.
- C. Take the medication with a full glass of milk.
- D. Expect your stools to be black and tarry.
Correct answer: A
Rationale: The correct instruction to include when teaching a client with a new prescription for Sulfasalazine is to expect orange discoloration of urine and skin. Sulfasalazine can cause this harmless side effect, which does not necessitate discontinuation of the medication. It is crucial for the nurse to educate the client about this expected outcome to prevent unnecessary concern or discontinuation of the medication. Choices B, C, and D are incorrect. Increasing intake of high-sodium foods is not recommended with Sulfasalazine, as it can worsen certain side effects. Taking the medication with a full glass of milk is not necessary for Sulfasalazine administration. Expecting stools to be black and tarry is not an expected side effect of Sulfasalazine.
4. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct answer: D
Rationale: Corrected Rationale: Early decelerations are caused by head compression resulting from the fetal head being compressed during contractions. They are considered benign and do not indicate fetal distress. Choice A, fetal hypoxia, is incorrect because early decelerations are not associated with fetal hypoxia. Choice B, abruptio placentae, is incorrect as it is a condition where the placenta prematurely separates from the uterine wall. Choice C, post maturity, is incorrect as it refers to a fetus that remains in the uterus past the due date.
5. The nurse is aware that if patients from different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what?
- A. Acculturation
- B. Ethnocentrism
- C. Cultural shock
- D. Cultural sensitivity
Correct answer: B
Rationale: Ethnocentrism is the belief that one's own culture is superior to others, which can lead to bias and a lack of cultural competence in healthcare.