ATI Comprehensive 2024 Exit Exam with NGN -Nurselytic

Questions 170

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ATI Comprehensive 2024 Exit Exam with NGN Questions

Extract:


Question 1 of 5

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

Correct Answer: B

Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (
A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (
C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (
D) is important, but addressing the dehydration issue takes priority.

Extract:

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.


Question 2 of 5

Which of the following actions should the nurse Include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Correct Answer: B

Rationale: The correct answer is B because acknowledging the client's emotions can help de-escalate the situation. By stating, "You seem to be very upset," the nurse shows empathy and understanding, which can help the client feel heard and validated. Using a face shield, engaging the panic alarm, or initiating seclusion protocol are not appropriate actions in this scenario as they do not address the client's emotional state or help in calming them down. Face shield and panic alarm are more related to safety precautions, while seclusion protocol should only be considered as a last resort for safety reasons.
Therefore, choice B is the most appropriate action for interacting with a client who is aggravated, pacing, and speaking loudly.

Extract:

A nurse in an emergency department is caring for a client.


Question 3 of 5

Select the 5 findings the nurse should plan to include in the report.

Correct Answer: A,C,D,E,F

Rationale: These findings highlight potential abuse and neglect indicators.

Extract:


Question 4 of 5

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?

Correct Answer: D

Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is crucial for diabetic foot care as it helps prevent moisture buildup, reduces the risk of infections, and maintains proper foot hygiene. Clean cotton socks minimize friction, provide cushioning, and promote good circulation.

Rationale for other choices:
A: Soaking feet twice daily can lead to dry skin, increasing the risk of skin breakdown and infection.
B: Rounding the edges of toenails can cause injury and increase the risk of ingrown toenails.
C: Using moisturizing lotion between the toes can create a moist environment, promoting fungal growth and skin maceration.

Extract:

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation.


Question 5 of 5

Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.


Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope.
Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate.
Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.

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