ATI RN
ATI RN Custom Exams Set 3 Questions
Question 1 of 5
The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?
Correct Answer: B
Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.
Question 2 of 5
The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?
Correct Answer: D
Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.
Question 3 of 5
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
Correct Answer: D
Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client's vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.
Question 4 of 5
What signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?
Correct Answer: A
Rationale: The correct answer is A: 'Nervousness, jitteriness, and diaphoresis.' Insulinomas cause hypoglycemia due to excessive insulin production, leading to symptoms such as nervousness (from the sympathetic response to hypoglycemia), jitteriness, and diaphoresis (sweating). Choices B, C, and D are incorrect. Flushed skin, dry mouth, and tented skin turgor (Choice B) are not typical signs of insulinoma. Polyuria, polydipsia, and polyphagia (Choice C) are classic symptoms of diabetes mellitus, not insulinoma. Hypertension, tachycardia, and feeling hot (Choice D) are more indicative of hyperthyroidism or a hypermetabolic state, rather than an insulinoma presentation.
Question 5 of 5
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.