ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A because the urethral orifice is located between the clitoris and the vaginal opening, so separating the labia minora allows for proper visualization and assessment. This step ensures accurate examination of the urethral opening for signs of infection or abnormalities. Palpating the cervix first (
B) is incorrect as it should be done after inspecting the external genitalia. Choosing not to inspect the external genitalia (
C) is incorrect as it is an essential part of the gynecological examination. Assessing the perineum after the vaginal examination (
D) is incorrect as the perineum should be assessed before the vaginal examination to evaluate for any abnormalities or injuries.
Question 2 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings shouldn't the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Increased hematocrit. In fluid overload, there is an excess of fluid in the body, leading to dilution of blood components including hematocrit.
Therefore, an increased hematocrit would not be expected. Increased heart rate (
A), blood pressure (
B), and respiratory rate (
C) are all common findings in fluid overload due to the body's compensatory mechanisms to maintain adequate perfusion. Thus, these findings are expected.
Question 3 of 5
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
Correct Answer: A
Rationale: The correct answer is A: It facilitates the client's deep breathing. Postoperative clients following CABG surgery are at risk for developing atelectasis due to decreased lung expansion. Opioid medications can cause respiratory depression, leading to shallow breathing. By facilitating deep breathing, the nurse helps prevent atelectasis and promotes optimal oxygenation, aiding in the client's recovery.
Choices B, C, and D are incorrect as they are not directly related to the immediate physiological needs of a postoperative CABG client. Increasing appetite, promoting wound healing, and decreasing anxiety are important aspects of overall recovery but are not as critical as ensuring proper oxygenation and preventing respiratory complications in the immediate postoperative period.
Question 4 of 5
A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?
Correct Answer: A
Rationale: The correct answer is A: Prevent the spread of infection with good household cleaning practices. The nurse should include this statement in the discharge instructions because individuals with AIDS have weakened immune systems, making them more susceptible to infections. Good household cleaning practices can help prevent the spread of infections to the client and others.
Incorrect choices:
B: Limit handwashing to once a day to avoid skin damage - This is incorrect as frequent handwashing is crucial to prevent the spread of infections.
C: Avoid sharing towels with other people in the household - This is incorrect as sharing towels can lead to the transmission of infections.
D: Do not disinfect surfaces in the home with bleach - This is incorrect as disinfecting surfaces with bleach is important to kill harmful pathogens.
Question 5 of 5
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Keep the drainage system below the level of the client's chest at all times. This is crucial because maintaining the drainage system below the chest level prevents backflow of air or fluid into the client's chest cavity, which can lead to complications like tension pneumothorax or fluid re-entering the pleural space. Clamping the chest tube can cause a build-up of pressure and should only be done in emergency situations. Removing the chest tube is unsafe and can lead to respiratory distress. Allowing the client to carry the drainage system can risk dislodging the tube or causing tension on the connections.
Therefore, the best option is to keep the drainage system below the chest level to ensure proper drainage and prevent complications.