ATI RN
ATI Comprehensive Predictor 2023 Exit Exam B Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote comfort?
Correct Answer: D
Rationale: Elevating the affected arm on a pillow promotes lymphatic drainage, reduces swelling, and enhances comfort after a mastectomy, where lymph nodes may have been removed.
Choice A is incorrect because, while deep-breathing exercises are beneficial for lung expansion, they do not directly address post-mastectomy comfort related to the surgical site.
Choice B is incorrect because a supine position with the head flat may increase swelling and discomfort; a semi-Fowler's position is preferred.
Choice C is incorrect because a warm compress is not recommended, as it may increase swelling or risk infection; cold packs may be used if prescribed.
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: C
Rationale: Discussing with the client his inappropriate behavior prior to seclusion is important, but it's not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client's behavior prior to seclusion. Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context. Documenting the client's behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention. Assessing the client's behavior once every hour is important to monitor the client's condition and response to seclusion. However, this is not the most appropriate action in this context.
Question 3 of 5
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
Correct Answer: C
Rationale:
Choice A is wrong because it is not a common complication of amniocentesis. Epigastric pain is more likely to be associated with preeclampsia, a condition that causes high blood pressure and proteinuria in pregnancy. Epigastric pain can indicate severe preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which are life-threatening complications that require immediate medical attention.
Choice B is wrong because it is not a direct result of amniocentesis. Hypertension can occur in pregnancy due to various factors, such as chronic hypertension, gestational hypertension, preeclampsia, or eclampsia. Hypertension can increase the risk of complications such as placental abruption, fetal growth restriction, preterm birth, and maternal stroke. According to the flashcards from Quizlet, a nurse should monitor a client who is at 33 weeks of gestation following an amniocentesis for contractions, as they are a sign of preterm labor and possible uterine rupture. An amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for testing. It can cause complications such as bleeding, infection, leakage of fluid, and injury to the fetus or placenta.
Choice D is wrong because it is not a typical complication of amniocentesis. Vomiting can occur in pregnancy due to various causes, such as morning sickness, gastroenteritis, food poisoning, or hyperemesis gravidarum. Vomiting can lead to dehydration, electrolyte imbalance, weight loss, and malnutrition if not treated properly.
Question 4 of 5
A nurse is assessing a client who has a spinal cord injury at the C5 level. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: A spinal cord injury at the C5 level typically preserves the function of the diaphragm (innervated by C3-C5) and shoulder muscles (deltoid and rotator cuff, innervated by C5), allowing the client to shrug shoulders.
Choice A is incorrect because a C5 injury affects the lower extremities, causing paraplegia or quadriplegia, depending on the extent.
Choice B is incorrect because, while respiratory function is partially preserved (diaphragm intact), the client may still have impaired accessory muscle function, leading to reduced respiratory capacity.
Choice C is incorrect because sensation loss typically occurs below the level of injury (below C5), not necessarily below the clavicles, and may vary in completeness.
Question 5 of 5
A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote comfort?
Correct Answer: D
Rationale: Elevating the affected arm on a pillow promotes lymphatic drainage, reduces swelling, and enhances comfort after a mastectomy, where lymph nodes may have been removed.
Choice A is incorrect because, while deep-breathing exercises are beneficial for lung expansion, they do not directly address post-mastectomy comfort related to the surgical site.
Choice B is incorrect because a supine position with the head flat may increase swelling and discomfort; a semi-Fowler's position is preferred.
Choice C is incorrect because a warm compress is not recommended, as it may increase swelling or risk infection; cold packs may be used if prescribed.