a patient is admitted to the hospital with complaints of nausea vomiting diarrhea and severe abdominal pain which of the following would immediately a
Logo

Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the healthcare provider that the patient has bleeding from the GI tract?

Correct answer: B

Rationale: A positive guaiac test is used to detect the presence of occult (hidden) blood in the stool, suggesting bleeding from the gastrointestinal tract. It is a rapid screening test that can provide immediate information to the healthcare provider about possible gastrointestinal bleeding in patients presenting with symptoms such as nausea, vomiting, diarrhea, and severe abdominal pain.

2. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

3. Which of the following clusters of data belong to Maslow’s hierarchy of needs?

Correct answer: D

Rationale: Maslow's hierarchy of needs is a theory in psychology that categorizes human needs into five levels: physiological needs, safety needs, love and belongingness, esteem needs, and self-actualization. 'Love and belonging' corresponds to the third level, 'Physiological needs' to the first level, and 'Self-actualization' to the highest level. Therefore, all the clusters listed in the choices are part of Maslow's hierarchy of needs. Selecting 'All of the above' (option D) is the correct answer as it includes all the clusters associated with Maslow's theory.

4. What is the most appropriate nursing order for a patient who develops dyspnea and shortness of breath?

Correct answer: B

Rationale: Maintaining the patient in an orthopneic position as needed is the most appropriate nursing order for a patient experiencing dyspnea and shortness of breath. This position helps to optimize lung expansion, improve oxygenation, and alleviate breathing difficulties. It is a strategic intervention to enhance respiratory function in patients with respiratory distress. Choice A is incorrect because strict bed rest may not address the underlying respiratory issue effectively. Choice C is premature as administering high-flow oxygen should be based on a comprehensive assessment. Choice D is inappropriate as encouraging vigorous physical activity can exacerbate breathing problems in a patient experiencing dyspnea.

5. During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

Correct answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

Similar Questions

Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
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?
What is the appropriate route of administration for insulin?
What is required for effective hand washing?
When educating a client who experienced a pneumothorax, which of the following statements should the nurse use?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses