ATI RN
ATI RN Custom Nursing 221 Exam 4 Questions
Extract:
Question 1 of 5
A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?
Correct Answer: C
Rationale: Candidiasis is common in AIDS due to a weakened immune system.
Question 2 of 5
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Checking for kinks is a simple, non-invasive first step to restore drainage.
Question 3 of 5
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
Correct Answer: D
Rationale: Black beans are a good source of iron to alleviate iron deficiency anemia.
Question 4 of 5
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
Correct Answer: B
Rationale: Impaired tissue perfusion is the priority due to poor blood flow causing ulcerations and edema.
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.