ATI RN
ATI RN Custom Exams Set 3
1. The healthcare provider is conducting a respiratory assessment and is determining respirations per minute. Which factor(s) generally affect the character of respirations? Select all that apply.
- A. Anxiety
- B. Exercise
- C. Smoking
- D. A, B
Correct answer: D
Rationale: Correct! Anxiety and exercise can significantly alter the character of respirations, increasing the rate and depth. Smoking, while harmful to the respiratory system in the long term, does not directly affect the character of respirations like anxiety and exercise do. Therefore, choices C (Smoking) is incorrect. The correct answer is D (A, B).
2. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?
- A. 32-year-old with diarrhea for 6 hours
- B. 2-year-old with 1 wet diaper in 24 hours
- C. 40-year-old with abdominal cramping
- D. 10-year-old who is nauseated
Correct answer: B
Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.
3. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?
- A. Measuring and recording fluid intake and output
- B. Weighing the client daily at the same time each day
- C. Assessing the client’s vital signs every 4 hours
- D. Checking the client’s lungs for crackles during every shift
Correct answer: B
Rationale: Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can reflect fluid retention or loss. Measuring and recording fluid intake and output (Choice A) is important but may not provide immediate changes in fluid status. Assessing vital signs (Choice C) can offer some information but may not be as specific to fluid status as daily weighing. Checking the client's lungs for crackles (Choice D) is more related to assessing respiratory status rather than direct fluid monitoring.
4. 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.
5. The client has failed to conceive after many attempts over a three-year time period and asks the nurse, “I have tried everything. What should I do now?” Which statement is the nurse’s best response?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client’s medication levels daily
- D. Monitor the percentage of each meal eaten
Correct answer: A
Rationale: The correct response is to assess the intravenous fluids for rate and volume. In this situation, the client is seeking guidance on fertility issues, not related to intravenous fluids, surgical dressing changes, medication levels, or meal monitoring. The nurse should provide supportive and empathetic guidance, suggesting further options like consulting fertility specialists or exploring additional treatments.
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