ATI RN
ATI Fundamentals Proctored Exam 2024
1. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
- A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
- B. Place a humidifier in the patient’s room
- C. Continue administering oxygen by high humidity face mask
- D. Perform chest physiotherapy on a regular schedule
Correct answer: D
Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.
2. A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer.
- B. FACES pain scale.
- C. Auscultate the newborn's apical pulse for 60 seconds.
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.
Correct answer: C: Auscultate the newborn's apical pulse for 60 seconds.
Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.
3. A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?
- A. There are portable oxygen delivery systems that you can take with you.
- B. When you go out, you can remove the oxygen and then reapply it when you get home.
- C. You probably will not be able to go out as much as you used to.
- D. Home health services will come to see you so you will not need to get out.
Correct answer: There are portable oxygen delivery systems that you can take with you.
Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.
4. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
5. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?
- A. Take quick breaths upon inhalation.
- B. Place your hand over your stomach.
- C. Take a deep breath in through your nose.
- D. Puff your cheeks upon exhalation.
Correct answer: C: Take a deep breath in through your nose.
Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.