RN ATI Comprehensive Assessment Exam Retake 2023 V2 -Nurselytic

Questions 58

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RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions

Extract:


Question 1 of 5

A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?

Correct Answer: D

Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.

Question 2 of 5

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Correct Answer: A

Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart's inability to pump effectively leads to fluid accumulation in the lungs, causing crackles on auscultation. Decreased thirst (
B) is not a typical manifestation. Poor skin turgor (
C) is more indicative of dehydration. Tachycardia (
D) may occur but is not specific to heart failure.

Question 3 of 5

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?

Correct Answer: C

Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.


Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.

Choice B: Protamine is used to reverse the effects of heparin, not opioids.

Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.


Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.

Question 4 of 5

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

Correct Answer: B

Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial to ensure the child's comfort and facilitate recovery. Administering analgesics on a scheduled basis helps maintain a consistent level of pain relief and prevents breakthrough pain. This approach is especially important in the immediate postoperative period when pain levels are typically higher. Options A, C, and D are incorrect because applying a warm compress, giving cromolyn nebulized solution, and offering clear liquids are not primary interventions for postoperative pain management in this scenario. Option D specifically is not recommended as clear liquids are usually introduced gradually to prevent complications. Providing analgesics on a scheduled basis is the best course of action to address the child's immediate postoperative pain effectively.

Question 5 of 5

A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?

Correct Answer: D

Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (
A) can come later. Inquiring about family suicide history (
B) may not be relevant at this stage. Involving others in care (
C) is important but not as urgent as assessing suicidal thoughts.

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