ATI Fundamentals Proctored Exams Retake (2023/2024) | 3 Versions with Questions and Rationalized Answers

ATI Fundamentals Proctored Exams Retake (2023/2024) | 3 Versions with Questions and Rationalized Answers A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates - ansA, B, C For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this way increases the risk for bleeding. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates - ansA, B, C For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all. A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temp. E. Discard any residual gastric contents. - ansA, B, C D-the formula should be room temp not body E-unless the volume of the contents is more than 250 mL, the nurse should return the residual content to the client's stomach A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available - ansA, B A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available - ansA, B An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, w/scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all. A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care - ansB, C An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, w/scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all. A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care - ansB, C A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A. Increase in incisional pain B. Fever & chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - ansA, B, C A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A. Increase in incisional pain B. Fever & chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - ansA, B, C A nursing instructor is reviewing the wound healing process w/a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all. A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed w/adhesive E. Open burn area - ansA, E B and D are healed w/primary intention C is not a skin wound unless bone has pierced the skin