ATI RN
ATI RN Exit Exam Quizlet
1. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?
- A. Insert a lubricated gloved finger and advance along the rectal wall
- B. Apply lubricant and stimulate peristalsis
- C. Apply pressure to the abdomen to assist with removal
- D. Increase fluid intake before the procedure
Correct answer: A
Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma to the client. Choice B is incorrect because stimulating peristalsis is not the appropriate action for digitally evacuating stool. Choice C is incorrect as applying pressure to the abdomen can be uncomfortable and ineffective. Choice D is also incorrect because increasing fluid intake is not directly related to the digital evacuation procedure.
2. How should a healthcare professional assess a patient for dehydration?
- A. Check for skin turgor
- B. Monitor blood pressure
- C. Check for dry mucous membranes
- D. Monitor urine output
Correct answer: A
Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.
3. A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Administer nitroglycerin sublingually.
- C. Obtain a 12-lead ECG.
- D. Notify the healthcare provider.
Correct answer: C
Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.
4. What is the most important assessment for a patient post-surgery?
- A. Monitor vital signs
- B. Check surgical site for bleeding
- C. Check for abnormal breath sounds
- D. Check skin color
Correct answer: A
Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.
5. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct answer: B
Rationale: The correct answer is B: Tachycardia. In acute alcohol withdrawal, tachycardia is a common finding due to increased sympathetic activity. Bradycardia (Choice A) is less likely in this condition since the sympathetic nervous system is typically overactive. Hyperthermia (Choice C) is not a typical finding in acute alcohol withdrawal. Hypotension (Choice D) is less common compared to tachycardia in this situation.
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