ATI RN Custom Exams Set 3

ATI RN Custom Exams Set 3 Related

Review ATI RN Custom Exams Set 3 related questions and content

The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

  • A. Assess the client's vital signs
  • B. Start an IV with an 18-gauge needle
  • C. Begin iced saline lavage
  • D. A, B
Correct Answer: D

Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client's vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.

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The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

  • A. Second intercostal space, right sternal border
  • B. Erb's point
  • C. Second intercostal space, left sternal border
  • D. Fourth intercostal space, left sternal border
Correct Answer: A

Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.

A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe a continuous infusion of insulin of:

  • A. Novolin L insulin
  • B. Novolin R insulin
  • C. Novolin N insulin
  • D. Novolin U insulin
Correct Answer: B

Rationale: The correct answer is Novolin R (Regular insulin). Regular insulin is used for continuous infusion to treat diabetic ketoacidosis due to its rapid onset of action. Novolin L (Intermediate-acting insulin) (choice A), Novolin N (Intermediate-acting insulin) (choice C), and Novolin U (Ultra-Long-acting insulin) (choice D) are not suitable for continuous infusion in the treatment of diabetic ketoacidosis.

The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

  • A. Deep tendon reflexes
  • B. Arterial blood gases
  • C. Skin turgor
  • D. Capillary refill time
Correct Answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

  • A. Encourage the client to drink liquids
  • B. Perform active range of motion exercises
  • C. Elevate the head of the bed to 45 degrees
  • D. Provide a high-fiber diet to the client
Correct Answer: B

Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.

Why may patients with hiatal hernia develop anemia?

  • A. Iron absorption is reduced
  • B. Gastritis may cause bleeding
  • C. Iron stores turn over more quickly
  • D. Patients have an aversion to foods that are good sources of iron
Correct Answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can lead to gastrointestinal bleeding, resulting in anemia due to blood loss. Choice A is incorrect because hiatal hernia does not directly affect iron absorption. Choice C is incorrect as iron stores turning over more quickly is not a typical reason for anemia in hiatal hernia patients. Choice D is incorrect as an aversion to iron-rich foods does not directly cause anemia in this context.

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