ATI RN
ATI RN Custom Exams Set 1
1. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?
- A. Explain to the client that it is too early to have an injection for pain
- B. Call the practitioner, report the client’s symptoms, and obtain further orders
- C. Reposition the client for greater comfort and turn on the television as a distraction
- D. Prepare the injection and administer it to the client early because of the severe pain
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to call the practitioner, report the client’s symptoms, and obtain further orders. The client's symptoms, including severe abdominal pain, pallor, perspiration, thready rapid pulse, and feeling faint, are indicative of potential complications like internal bleeding, which require immediate medical evaluation. Explaining to the client that it is too early for pain medication or repositioning the client for comfort are not appropriate actions given the severity of the symptoms. Administering the injection early without consulting the practitioner can be dangerous and may worsen the client's condition.
2. The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?
- A. The client lies flat in the supine position for 12 hours
- B. The client continues oral fluids restriction while on bed rest
- C. The client’s family changed the dressing on return to the room
- D. The family activates the patient-controlled analgesia pump
Correct answer: A
Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy is essential to prevent bleeding and promote recovery. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Choices B, C, and D are incorrect because continuing oral fluids restriction, changing the dressing, and activating the patient-controlled analgesia pump do not directly indicate compliance with the crucial post-biopsy teaching of maintaining the supine position.
3. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?
- A. Frequent aspirin (acetylsalicylic acid) and a non-narcotic analgesic
- B. Motrin (ibuprofen), an NSAID, PRN
- C. Demerol (meperidine), a narcotic analgesic, every four (4) hours
- D. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN
Correct answer: D
Rationale: In a sickle cell crisis, morphine is the preferred analgesic due to its potency and effectiveness in managing severe pain. Choice A is incorrect because aspirin is contraindicated in sickle cell disease due to its potential to cause a further decrease in blood flow. Choice B, Motrin (ibuprofen), is also not the ideal choice as NSAIDs can exacerbate renal complications in sickle cell patients. Choice C, Demerol (meperidine), is not recommended for sickle cell pain management due to its toxic metabolite accumulation which can cause seizures and other complications.
4. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:
- A. Astride one of her hips
- B. Strapped in an infant seat
- C. Wrapped tightly in a blanket
- D. Under the arm using a football hold
Correct answer: A
Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.
5. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?
- A. Explain to the client that it is too early to have an injection for pain
- B. Call the practitioner, report the client’s symptoms, and obtain further orders
- C. Reposition the client for greater comfort and turn on the television as a distraction
- D. Prepare the injection and administer it to the client early because of the severe pain
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client’s symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.
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