RN ATI FUNDAMENTALS OF NURSING
PROCTORED EXAM 2023 REVISED
EDITION
102 - ANSWERSA nurse is assessing a client who is reporting severe pain despite
... [Show More] analgesia. The nurse
can best assess the intensity of the client's pain by:
A. asking what precipitates the pain
B. questioning the client about the location of the pain
C. offering the client a pain scale to measure his pain
D. using open-ended questions to identify the situation - ANSWERS-C.
pain scale can measure the amount and intensity of the pain
A nurse is assessing a client who reports pain when the nurse evaluates the internal
rotation of her right shoulder. Which of the following activities is this problem likely to
affect?
A. Mopping her floors
B. Brushing the back of her hair
C. Fastening her bra behind her back
D. Reaching into a cabinet above her sink - ANSWERS-C.
Fastening a bra from behind requires internal rotation of the shoulder, so this activity will
illicit pain
A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia.
Which of the following findings should the nurse document as extrapyramidal symptoms
(EPS)? Select all.
A. Orthostatic hypotension
B. Fine motor tremors
C. Acute dystonias
D. Decreased level of consciousness
E. Uncontrollable restlessness - ANSWERS-B, C, E
A and D are adverse effects, but not EPS
A nurse is assessing the pain level of a client who has come to the ER reporting severe
abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The
nurse is assessing which of the following?
A. Presence of associated symptoms
B. Location of the pain
C. Pain quality
D. Aggravating & relieving factors - ANSWERS-A.
this is a common symptom people have when experiencing pain
A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS).
The nurse is aware that health care professionals are required to report communicable
& infectious diseases. Which of the following illustrate the rationale for reporting? Select
all.
A. Planning & evaluating control & prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks - ANSWERS-A, B, C, E
Not D because endemic disease is already prevalent within a population, so reporting is
not necessary
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. - ANSWERS-A, 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 caring for a client who has a tracheostomy. Which of the following actions
should the nurse take each time he provides tracheostomy care? Select all.
A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
B. Use surgical asepsis to remove & clean the inner cannula
C. Clean the outer surfaces in a circular motion from the stoma site onward
D. Replace the tracheostomy ties w/new ties
E. Cut a slit in gauze squares to place beneath the tube holder. - ANSWERS-A, B, C
D-only replace ties if soiled or wet
E-use a commercially prepared gauze w/slit not one nurse makes [Show Less]