ATI RN
ATI RN Custom Exams Set 3
1. Protecting the rights and privacy of the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: C
Rationale: The correct answer is C: Implementation. Implementation is the phase where the nursing care plan is put into action, which includes safeguarding the patient's and their family's rights and privacy. Evaluation (choice A) involves reviewing the effectiveness of the care plan, Planning (choice B) is the phase where the care plan is developed, and Assessment (choice D) is the initial step where data about the patient is collected.
2. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by immobility
Correct answer: C
Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.
3. A client is prescribed Omeprazole for managing heartburn. What information should the nurse include in the teaching?
- A. Take this medication at bedtime.
- B. This medication decreases the production of gastric acid.
- C. Take this medication 2 hours after eating.
- D. This medication can cause hyperkalemia.
Correct answer: B
Rationale: The correct answer is B. The nurse should educate the client that Omeprazole works by reducing the production of gastric acid through inhibiting the enzyme responsible for its production. This action helps in managing heartburn and related symptoms effectively. Choice A is incorrect because Omeprazole is usually taken before eating. Choice C is incorrect as Omeprazole is typically taken before a meal. Choice D is unrelated to Omeprazole, as it is not associated with causing hyperkalemia.
4. What do positive feedback mechanisms do?
- A. Cause long-term changes.
- B. Move conditions away from the normal state.
- C. Bring conditions back to the normal state.
- D. Usually produce stable conditions.
Correct answer: Move conditions away from the normal state.
Rationale: Positive feedback mechanisms amplify or increase changes in a system, moving conditions away from the normal state. This makes choice B the correct answer. Choice A is incorrect as positive feedback does not cause long-term changes but rather accelerates deviations from the norm. Choice C is incorrect because positive feedback does not bring conditions back to normal; instead, it amplifies deviations. Choice D is incorrect as positive feedback does not usually lead to stable conditions but rather to further deviations from the normal state.
5. When caring for a client with acute renal failure, which laboratory value is most important to monitor?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum chloride
Correct answer: B
Rationale: In acute renal failure, monitoring serum potassium is crucial because impaired kidney function can lead to hyperkalemia, which can result in life-threatening cardiac dysrhythmias. Elevated potassium levels need close monitoring and prompt interventions to prevent serious complications.