ATI RN
ATI Maternal Newborn Exam 3 Fall 2023 Questions
Extract:
A client receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence.
Question 1 of 5
A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Provide regular perineal care to prevent skin breakdown. Reflex incontinence can lead to frequent and involuntary voiding, increasing the risk of skin breakdown. Regular perineal care helps maintain skin integrity and prevent complications. Limiting fluid intake (
A) is not appropriate as it may lead to dehydration. Administering hypotonic IV fluids (
C) is not related to managing reflex incontinence. Teaching Kegel exercises (
D) is more suitable for stress incontinence, not reflex incontinence.
Extract:
Question 2 of 5
An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?
Correct Answer: B
Rationale: The correct answer is B: Help plant workers identify signs of carpal tunnel syndrome. This is a secondary prevention strategy because it involves early detection and intervention before the condition progresses. By educating workers about the signs of carpal tunnel syndrome, the nurse can help them seek timely medical attention, potentially preventing further complications.
Option A is incorrect because it focuses on rehabilitation and return-to-work programs, which are more aligned with tertiary prevention. Option C involves primary prevention through vaccination. Option D is about teaching proper lifting techniques, which is more of a primary prevention strategy to prevent injuries.
Extract:
A client who is receiving total parenteral nutrition (TPN).
Question 3 of 5
Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?
Correct Answer: A
Rationale: The correct answer is A: Collect fingerstick glucose levels. This is crucial for monitoring the client's blood sugar levels due to the high glucose content in TPN. Monitoring blood sugar helps prevent hyperglycemia or hypoglycemia. Implementing bleeding precautions (
B) is not directly related to TPN administration. Obtaining daily weights (
C) is important but not the most critical intervention. Checking urine for albumin (
D) is more relevant for monitoring kidney function rather than TPN.
Extract:
A client with complications of left-sided heart failure.
Question 4 of 5
The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first?
Correct Answer: C
Rationale: The correct answer is C: Bilateral lung sounds. In left-sided heart failure, fluid accumulates in the lungs causing respiratory symptoms. Assessing lung sounds first helps identify any signs of pulmonary congestion, such as crackles or wheezes. This is crucial for immediate intervention to prevent respiratory distress. Heart sounds (
A) and chest pain (
B) are important but assessing lung sounds takes priority to address the immediate respiratory distress. Mood and affect (
D) assessment is important but not urgent in this situation.
Extract:
A hospitalized client.
Question 5 of 5
An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?
Correct Answer: C
Rationale: The correct answer is C. The enema solution should approximate the client's body temperature (98°F or 36°
C) to prevent discomfort or injury. Administering the enema at this temperature helps relax the colon muscles and promote retention of the solution.
Choice A is incorrect because the solution temperature should not solely be determined by client comfort as it must align with physiological considerations.
Choice B is incorrect as the temperature of the enema solution does impact its effectiveness by affecting the colon's response.
Choice D is incorrect as a temperature higher than the body temperature can cause burns or discomfort.