ATI RN
ATI Comprehensive 2024 Exit Exam with NGN Questions
Extract:
A nurse is caring for a client who has a spinal cord injury.
Question 1 of 5
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
| Potential Nursing Action | Anticipated | Contraindicated |
|---|---|---|
| Perform suctioning | ||
| Assess for urinary retention. | ||
| Assess blood pressure every 15 min | ||
| Withhold pain medication for headache until other manifestations resolve. | ||
| Place client in supine position | ||
| Administer nifedipine. |
Correct Answer:
Rationale: Rationales provided within the question context.
Extract:
Question 2 of 5
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Sunken fontanels and dry mucous membranes. These findings indicate severe dehydration in the infant, which is a critical condition that requires immediate intervention. Sunken fontanels suggest significant fluid loss, while dry mucous membranes are indicative of dehydration. Reporting these findings to the provider is crucial for prompt treatment to prevent further complications.
Incorrect Answer A: Pale and a 24 hr fluid deficit of 30 ml. Pale skin alone may not indicate severe dehydration, and a 24-hour fluid deficit of 30 ml is relatively small and not alarming.
Incorrect Answer C: Decreased appetite and irritability. These are common symptoms of gastroenteritis and may not necessarily indicate a need for immediate reporting to the provider.
Incorrect Answer D: Temperature 38° C and pulse rate 124/min. These vital signs are elevated but do not directly indicate severe dehydration requiring immediate reporting.
Question 3 of 5
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect
Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.
Question 4 of 5
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Correct Answer: A
Rationale: The correct answer is A. When setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come into contact with the sterile solution, remains uncontaminated. Placing the cap sterile-side up prevents any potential contaminants from coming into contact with the solution. This practice follows aseptic technique guidelines to prevent the introduction of pathogens.
Choices B, C, and D are incorrect because they do not address the key principle of maintaining sterility. Placing sterile gauze over spilled solution (
B) can introduce contaminants to the field, holding the bottle in the center (
C) does not prevent contamination, and the orientation of the label (
D) does not affect sterility.
Question 5 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 legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice
B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice
C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice
D) may escalate the situation and is not recommended in this scenario.