ATI RN
ATI Comprehensive 2024 Exit Exam with NGN Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (
A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (
C) is important but does not address the legal requirement of informed consent. While determining medical necessity (
D) is important, in this case, the primary concern is obtaining informed consent.
Question 4 of 5
The client asks the nurse if the medication can be given 2 hr. earlier. Which of the following statements should the nurse make?
Correct Answer: D
Rationale: The correct answer is D because it adheres to safe medication administration practices. The nurse should explain to the client that there is a window of up to 2 hours after the usual schedule time to administer the medication safely. This ensures that the medication remains effective while also preventing any potential harm from giving it too early or too late.
Choice A is incorrect because starting the medication 30 minutes earlier may not fall within the safe administration window.
Choice B is incorrect because adjusting the time solely based on convenience may compromise the medication's effectiveness.
Choice C is incorrect because infusing the medication at a faster rate could lead to adverse effects.
Question 5 of 5
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice
B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice
C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice
D) may escalate the situation and is not recommended in this scenario.