ATI Comprehensive 2024 Exit Exam with NGN -Nurselytic

Questions 170

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ATI Comprehensive 2024 Exit Exam with NGN Questions

Extract:

A nurse is reviewing the medical records of four clients.


Question 1 of 5

The nurse should identify that which of the following client findings requires follow-up care?

Correct Answer: C

Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.

Extract:


Question 2 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 3 of 5

A nurse is admitting a client who has schizophrenia. The client state nurse to state?"I'm hearing voices. Which of the following responses is the priority for the nurse to state"

Correct Answer: A

Rationale: The correct answer is A: "What are the voices telling you?" This response shows active listening and encourages the client to express their thoughts, helping the nurse assess the content and potential danger of the voices.
Choice B dismisses the client's experience, choice C focuses on medication compliance rather than immediate safety, and choice D is relevant but does not address the immediate concern.

Extract:

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby.


Question 4 of 5

Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Medicaid can provide financial assistance for prenatal care and delivery.

Extract:


Question 5 of 5

A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to assistive personnel?

Correct Answer: D

Rationale:
Correct Answer: D. Remind the client to use the incentive spirometer.


Rationale:
1. Incentive spirometer use is a task that can be safely delegated to assistive personnel.
2. It is a non-invasive procedure and does not require advanced nursing skills.
3. Using the incentive spirometer helps prevent respiratory complications post-surgery.
4. Assistive personnel can remind the client to use it regularly, promoting lung expansion and preventing atelectasis.

Summary of other choices:
A: Asking the client to describe pain requires nursing assessment skills.
B: Checking the client's pedal pulse requires nursing assessment skills.
C: Observing the position of the suspended weight requires nursing judgment to adjust if needed.

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