ATI RN
ATI Fundamentals
1. A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
- A. Impulse control difficulty
- B. Poor judgement
- C. Inability to recognize familiar objects
- D. Loss of depth perception
Correct answer: C
Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.
2. Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct answer: D
Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.
3. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct answer: D
Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.
4. The healthcare professional prepares to administer buccal medication. The medicine should be placed...
- A. On the client's skin
- B. Between the client's cheeks and gums
- C. Under the client's tongue
- D. On the client's conjunctiva
Correct answer: B
Rationale: Buccal medication is administered by placing it between the client's cheeks and gums. This route allows for the medication to be absorbed through the mucous membranes in the mouth, providing a rapid onset of action compared to oral ingestion. Placing the medication under the tongue (sublingual) allows for absorption through the sublingual mucosa, not the buccal mucosa. Placing medication on the skin or the conjunctiva is not appropriate for buccal administration.
5. When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?
- A. Psychologist
- B. Social worker
- C. Occupational therapist
- D. Speech-language pathologist
Correct answer: D
Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.
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