ATI RN
ATI RN Custom Nursing 221 Exam 4 Questions
Extract:
Question 1 of 5
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Correct Answer: D
Rationale: Left hemispheric CVA often impairs language, making communication a key goal.
Question 2 of 5
A charge nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?
Correct Answer: B
Rationale: Chlorhexidine is recommended for hand hygiene when caring for immunosuppressed clients as it has broad-spectrum antimicrobial activity. Alcohol-based hand rubs can irritate eyes, are ineffective against Clostridium difficile, and artificial nails harbor pathogens.
Question 3 of 5
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?
Correct Answer: A
Rationale: Increasing fluid intake replaces cerebrospinal fluid, alleviating headache.
Question 4 of 5
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Correct Answer: A
Rationale: Inspecting the mouth for signs of inhalation injuries is the priority action as inhalation injuries can lead to airway obstruction and respiratory failure.
Extract:
Nurses' Notes
0800: Client is 3 days postoperative.
Currently disoriented to time and place, oriented to self.
Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times.
Client attempts to get out of bed without assistance.
Changes in client's behavior began the prior evening, and the client has been awake most of the night.
Client has refused to eat or drink since the previous day.
Intake and output from the previous day: 250 mL intake, 2,500 mL output.
A call placed to the provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per the provider's prescription.
The client continues to be restless.
Vital Signs
• Heart rate 115/min
• Respiratory rate 20/min
• BP 90/65 mm Hg
• Temperature 38.6°C (101.5°F)
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
Correct Answer: C, D, E, B, E
Rationale: Condition: Delirium due to acute confusion and fever. Actions: Monitor fluid intake/output for dehydration; encourage family presence for reorientation. Parameters: Sleep-wake cycle and fall risk to assess delirium and safety.