ATI RN
ATI Fundamentals Proctored Exam 2024
1. Which of the following parameters should be checked when assessing respirations?
- A. Rate
- B. Rhythm
- C. Symmetry
- D. All of the above
Correct answer: D
Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.
2. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct answer: B
Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.
3. A nurse recognizes which of the following as a primary goal of nursing?
- A. Assist patients to achieve a peaceful death.
- B. Improve personal knowledge and skills to enhance patient outcomes.
- C. Advocate for quality of life over the quantity of life.
- D. Work to control costs to enhance patients' quality of life.
Correct answer: A
Rationale: The correct answer is A: 'Assist patients to achieve a peaceful death.' One of the primary goals of nursing is to help patients experience a comfortable and peaceful passing when faced with terminal illness or at the end of life. This involves providing holistic care, managing symptoms, and ensuring that patients are as comfortable and pain-free as possible. Choices B, C, and D are incorrect because while improving knowledge and skills, advocating for quality of life, and controlling costs are important aspects of nursing care, they are not the primary goal related to end-of-life care.
4. A client is to receive Tetracaine prior to a Bronchoscopy. Which of the following actions should the nurse include in the plan of care?
- A. Keep the client NPO until the pharyngeal response returns.
- B. Monitor the insertion site for a hematoma.
- C. Palpate the bladder to detect urinary retention.
- D. Maintain the client on bed rest for 12 hours following the procedure.
Correct answer: A
Rationale: The correct action the nurse should include in the plan of care is to keep the client NPO until the pharyngeal response returns. This is important to prevent aspiration until the client's normal pharyngeal sensation is restored, typically within about 1 hour after the procedure. Monitoring the insertion site for a hematoma, palpating the bladder, and maintaining the client on bed rest are not directly related to the administration of Tetracaine prior to a Bronchoscopy. Therefore, these actions are not necessary in the immediate post-procedure care of a client receiving Tetracaine for a Bronchoscopy.
5. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?
- A. Discontinue the procedure.
- B. Lower the height of the enema container.
- C. Complete the procedure as quickly as possible.
- D. Continue administration of the enema as ordered without making any adjustments.
Correct answer: B
Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.