ATI RN
ATI Comprehensive 2024 Exit Exam with NGN Questions
Extract:
Question 1 of 5
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who just drank orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications like seizures or loss of consciousness. Assessing and addressing the client's blood glucose level promptly is crucial to prevent harm.
Choice A is not the priority as the client scheduled for a procedure in 1 hour can wait for assessment until after the client with low blood glucose is evaluated.
Choice B, the client who received pain medication 30 minutes ago, can be assessed after the client with low blood glucose since the medication's effects have likely already taken place.
Choice D, the client with 100 mL of fluid remaining in the IV bag, can also wait for assessment as it does not pose an immediate threat to the client's health compared to low blood glucose.
Therefore, prioritizing the assessment of the client with low blood glucose is crucial to ensure their safety and well-being.
Question 2 of 5
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (
A) or placing them in a high-Fowler's position (
C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (
D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.
Question 3 of 5
A nurse is admitting a client who has schizophrenia. The client state nurse to state?"I'm hearing voices. Which of the following responses is the priority for the nurse to state"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response shows active listening and encourages the client to express their thoughts, helping the nurse assess the content and potential danger of the voices.
Choice B dismisses the client's experience, choice C focuses on medication compliance rather than immediate safety, and choice D is relevant but does not address the immediate concern.
Question 4 of 5
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
Correct Answer: B
Rationale: The correct answer is B: Weight Loss. Furosemide is a loop diuretic that helps the body excrete excess fluid and sodium through increased urine output.
Therefore, weight loss would indicate that the medication has been effective in reducing the client's fluid volume excess. Increased blood pressure (
A) would not be an expected finding as furosemide typically helps lower blood pressure. Decreased inflammation (
C) and decreased pain (
D) are not directly related to the action of furosemide as a diuretic.
Question 5 of 5
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Order the Items
Source Container
Correct Answer: C,D,E,A,B
Rationale:
To perform nasotracheal suctioning correctly, the nurse should follow these steps:
1. Dan sterile gloves (
C): Ensures aseptic technique to prevent infection.
2. Insert the catheter during the client's inspiration (
D): Reduces the risk of hypoxia and trauma.
3. Turn on the suction and set the pressure (E): Prepares the equipment for suctioning.
4. Apply suction while rotating the catheter (
A): Maximizes removal of secretions.
5. Rinse the catheter to remove secretions (
B): Ensures cleanliness of the catheter for next use.
Other choices are incorrect:
- F and G are not applicable in this sequence as they do not contribute to the safe and effective performance of nasotracheal suctioning.