ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. In clients receiving magnesium sulfate for preeclampsia, monitoring deep tendon reflexes is crucial as magnesium sulfate can lead to muscle weakness and decreased reflexes, indicating potential toxicity. Monitoring for 2+ reflexes ensures the client is within the therapeutic range. Pulse rate (
B) and urine output (
C) are important to monitor but are not specific therapeutic effects of magnesium sulfate. Proteinuria (
D) is a sign of preeclampsia and not a therapeutic effect of the medication.
Question 2 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 maintaining accurate and detailed records of the client's behavior leading up to seclusion, which can help in evaluating the appropriateness of the intervention and in providing important information for the client's treatment plan. Assessing the client's behavior once every hour is important but not the most appropriate immediate action. Offering fluids every 2 hours is not directly related to the client's need for seclusion. Discussing with the client his inappropriate behavior prior to seclusion may not be appropriate or safe in the context of needing seclusion to prevent harm.
Question 3 of 5
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. A constant P-R interval of 0.35 seconds indicates a prolonged conduction time between the atria and ventricles. In first-degree AV block, there is a delay in the conduction through the AV node, resulting in a prolonged P-R interval. This dysrhythmia is characterized by a consistent delay without dropped beats.
Choice B (Complete heart block) would present with a variable P-R interval and complete dissociation between atrial and ventricular activity.
Choice C (Premature atrial complexes) are early electrical impulses originating in the atria, not involving the AV node.
Choice D (Atrial fibrillation) would show irregular and chaotic atrial activity without a consistent P-R interval.
Question 4 of 5
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale: Limiting daily naps to 45 minutes can help improve nighttime sleep by reducing the drive to sleep during the day, promoting better sleep efficiency. This indicates an understanding of good sleep hygiene practices.
Summary of Incorrect
Choices:
A: Turning on the ceiling fan might help with white noise, but it does not address the underlying issue of insomnia.
C: Green tea contains caffeine, which can actually interfere with sleep and worsen insomnia.
D: Getting out of bed if unable to fall asleep within an hour can reinforce negative sleep associations and disrupt sleep patterns.
Extract:
Laboratory Results 1200: Hgb 9.5 g/dL (14 to 18 g/dL)
Hct 38% (42% to 52%) Bilrubin 5.3 mg/dl (0.3 to 1.0 mg/dL) [ instruct the client to avoid blowing their nose forcefully.
Creatinine 1.8 mg/dL (0.6 to 1.3 mg/dL) [ Assess the dlent’s level of oientation
Platelet count 100,000/mm? (150,000 to 400,000/mm?)
[ Place the client under contact isolation.
1800:
Alanine aminotransferase ALT 51 units/L (4 to 36 units/L) Aspartate aminotransferase AST 48 units/L (0 to 35 units/L)
Alkaline phosphate ALP 151 units/L (30 to 120 units/L) Blood total protein 15 g/dL (6.4 to 8.3 g/dL
Question 5 of 5
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
Correct Answer: A,B,C,E,F
Rationale:
Correct Answer: A,B,C,E,F
Rationale:
A: Providing frequent rest periods aids in the client's recovery and prevents fatigue.
B: Restricting sodium intake is crucial for clients with certain conditions like hypertension.
C: Avoiding soap and alcohol-based lotions can prevent skin irritation, especially for sensitive skin.
E: Blowing nose forcefully can cause ear issues, so advising against it is essential.
F: Assessing orientation helps monitor the client's cognitive status and detect any changes early.
Summary:
D: There is no indication in the scenario to place the client on a low-carbohydrate diet.
G: Option G is missing, so it cannot be considered as a valid action in this context.