ATI RN
ATI RN Custom Exams Set 3
1. 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.
2. Which physiologic response is most likely to accompany activation of the parasympathetic nervous system?
- A. Increased heart rate
- B. Increased gastric motility
- C. Pupil dilation
- D. Sweating
Correct answer: B
Rationale: The correct answer is B: Increased gastric motility. The parasympathetic nervous system is known to promote rest and digest functions, which includes increasing gastric motility to aid in digestion. Choices A, C, and D are incorrect as they are more characteristic of the sympathetic nervous system. The sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate (Choice A), pupil dilation (Choice C), and sweating (Choice D) among other responses.
3. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct answer: C
Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.
4. Which statement best reflects a top-down approach to the evaluation process?
- A. OT focuses on evaluating the child's poor performance in hand skills
- B. OT conducts an assessment to determine a motor age for fine motor and gross motor skills
- C. OT initiates by interviewing the family about routines, interests, and daily habits
- D. OT starts by assessing muscle tone, postural control, and range of motion
Correct answer: C
Rationale: A top-down evaluation approach in occupational therapy begins with understanding the child's daily life, family routines, interests, and habits to ensure that the therapy provided is relevant and meaningful within the child's natural environment. By initiating the evaluation process with family interviews to gather contextual information, the occupational therapist gains a comprehensive view of the child's life, which allows for a more holistic and client-centered approach. Choice A focuses solely on the child's poor performance in hand skills, which is more characteristic of a bottom-up approach. Choice B mentions determining a motor age, which is not necessarily aligned with a top-down assessment. Choice D emphasizes physical assessments like muscle tone and range of motion, which are important but do not capture the essence of a top-down approach that considers the child's environment and routines.
5. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse report to the provider?
- A. Serum calcium level of 8 mg/dL.
- B. Urine output of 60 mL/hr.
- C. Heart rate of 110/min.
- D. Temperature of 37.5°C (99.5°F).
Correct answer: C
Rationale: The correct answer is C. A heart rate of 110/min is elevated and may indicate hypocalcemia, a potential complication following a thyroidectomy. Elevated heart rate can be a sign of hypocalcemia due to the close relationship between calcium levels and cardiac function. Option A, serum calcium level of 8 mg/dL, is within the normal range (8.5-10.5 mg/dL) and would not be a cause for concern post-thyroidectomy. Option B, urine output of 60 mL/hr, is within the normal range for urine output and not typically a priority finding post-thyroidectomy. Option D, a temperature of 37.5°C (99.5°F), is slightly elevated but not a critical finding post-thyroidectomy unless accompanied by other symptoms.