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 auscultating for crackles on a client who has pneumonia.


Question 1 of 5

Which of the following anterior chest wall locations should the nurse auscultate?(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer:

Rationale:
Correct Answer: D (Second intercostal space, right sternal border)


Rationale: The nurse should auscultate at the second intercostal space, right sternal border to listen to the aortic valve. This location corresponds to the area where the aortic valve can be best heard. The aortic valve is located in the second intercostal space, right sternal border, so auscultating at this spot allows for accurate assessment of the heart sounds in this area. It is essential to auscultate at this specific location to detect any abnormalities or abnormalities in the aortic valve.

Summary of other choices:
- A, B, C, E, F, G: These locations do not correspond to the specific area where the aortic valve is best heard. Auscultating at these locations may not provide clear or accurate heart sounds related to the aortic valve.

Extract:


Question 2 of 5

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

Correct Answer: C

Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice
B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice
A) may not be concerning during labor. Contractions lasting 80 seconds (choice
D) can be normal in active labor.

Extract:

A nurse is caring for a client in the medical surgical unit.


Question 3 of 5

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Correct Answer: D,E

Rationale: Proper hygiene and regular assessment of catheter necessity reduce UTI risks.

Extract:


Question 4 of 5

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

Correct Answer: B

Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (
A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (
C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (
D) is important, but addressing the dehydration issue takes priority.

Extract:

A nurse is reviewing the medical records of four clients.


Question 5 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.

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