ATI Comprehensive 2024 Exit Exam with NGN -Nurselytic

Questions 170

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ATI Comprehensive 2024 Exit Exam with NGN Questions

Extract:

A nurse is caring for a client.


Question 1 of 5

Select the 5 findings that require immediate follow-up

Correct Answer: A,B,D,E,H

Rationale: The correct choices for immediate follow-up are A, B, D, E, and H. Stool results (
A) are crucial for detecting gastrointestinal issues. Hemoglobin and hematocrit (
B) levels indicate blood health. Heart rate (
D) reflects cardiovascular function. Current medications (E) help assess potential drug interactions. WIC count (H) is essential for monitoring infection. Respiratory rate (
C) and temperature (F) are important but not as urgent.

Extract:

A nurse reviews the entries in the medical record.


Question 2 of 5

For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Potential Prescription Anticipated Not Indicated
Document the blood product transfusion in the client's medical record.
Stay with the client for the first 15 min of the transfusion
Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
Obtain the first unit of packed RBCS from the blood bank.
Start an IV bolus of lactated Ringers solution.

Correct Answer: A,B,D

Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.

Extract:


Question 3 of 5

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

Correct Answer: B

Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (
A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (
C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (
D) is important, but addressing the dehydration issue takes priority.

Extract:

A nurse in an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a fractured radius.


Question 4 of 5

Which of the following information provided by the client indicates improvement? Select all that apply.

Correct Answer: B,C,D,E,F

Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.

Extract:

A nurse is caring for a client who is receiving total parenteral nutrition(TPN): The bag has 20 mL remaining to infuse, but a new bag is not readily available.


Question 5 of 5

Which of the following actions should the nurse take?

Correct Answer: A

Rationale: The correct answer is A: Administer dextrose 10% in water. This action is appropriate for treating hypoglycemia, which can be a potential complication of TPN (
Total Parenteral Nutrition) therapy. Administering dextrose 10% in water can help raise the patient's blood sugar levels quickly and effectively.
Choice B is incorrect as lactated Ringers solution does not directly address hypoglycemia.
Choice C is not the best option as slowing the TPN infusion rate may further decrease the patient's blood sugar levels.
Choice D is also incorrect as temporarily discontinuing the TPN infusion may exacerbate the hypoglycemia.

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