ATI RN Custom Exams Set 4

ATI RN Custom Exams Set 4 Related

Review ATI RN Custom Exams Set 4 related questions and content

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

  • A. Establish a rapport to foster trust
  • B. Place the client in full restraints
  • C. Try to communicate with the client in writing
  • D. Ensure safety by initiating suicide precautions
Correct Answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

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Which of the following is a common side effect of the drug metformin?

  • A. Weight loss
  • B. Weight gain
  • C. Drowsiness
  • D. Hypertension
Correct Answer: A

Rationale: The correct answer is A, weight loss. Metformin is commonly associated with weight loss rather than weight gain. Metformin works by decreasing glucose production in the liver and improving insulin sensitivity, which can lead to weight loss in some individuals. Choices B, C, and D are incorrect. Weight gain is not a typical side effect of metformin. Drowsiness and hypertension are also not commonly associated with metformin use.

The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client?

  • A. Keep the area between the toes dry.
  • B. Wear comfortable, well-fitting shoes.
  • C. Cut toenails straight across.
  • D. A,B
Correct Answer: D

Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry to prevent moisture-related skin issues and wearing comfortable, well-fitting shoes to prevent injury and promote circulation. Cutting toenails straight across is important to prevent ingrown toenails, but in this case, an arch cut can lead to injury. Therefore, choices A and B are correct, making option D the most appropriate answer. Choice C is incorrect in this context.

Which of the following is the primary enlisted personnel performing nursing care duties at the various levels of health care?

  • A. 68A30
  • B. 68WM6
  • C. Physician assistant
  • D. 6.80E+21
Correct Answer: B

Rationale: The correct answer is B: '68WM6'. The 68WM6 (Practical Nurse) is the primary enlisted personnel responsible for performing nursing care duties at various levels of health care. This choice is correct as it specifically identifies the enlisted personnel role related to nursing care. Choice A (68A30) is incorrect as it does not pertain to nursing care duties. Choice C (Physician assistant) is incorrect as physician assistants are not typically enlisted personnel. Choice D (6.80E+21) is incorrect as it is a numerical value and not a designation for enlisted personnel.

The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

  • A. The client with an abdominal aortic aneurysm who is constipated
  • B. The client on bed rest who ambulated to the bathroom
  • C. The client with essential hypertension who has epistaxis and a headache
  • D. The client with arterial occlusive disease who has a decreased pedal pulse
Correct Answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.

Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

  • A. The client will void a minimum of 30 mL per hour
  • B. The client will have elastic skin turgor
  • C. The client will have no adventitious breath sounds
  • D. The client will have a serum creatinine of 1.4 mg/dL
Correct Answer: C

Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.

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