ATI RN
ATI RN Custom Exams Set 2
1. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics
- B. Apply warm moist packs every two hours
- C. Elevate the right foot on two pillows
- D. Teach the client about skin and foot care
Correct answer: A
Rationale: Administering intravenous antibiotics is the priority intervention in this situation. Cellulitis is a bacterial infection that can spread rapidly, especially in individuals with diabetes. Immediate antibiotic therapy is crucial to prevent the infection from worsening and causing serious complications. Applying warm moist packs, elevating the foot, and teaching the client about skin and foot care are important interventions but should come after initiating antibiotic treatment to address the underlying infection.
2. During the acute phase of a burn, the priority nursing intervention in caring for this client is:
- A. Prevention of infection
- B. Pain management
- C. Prevention of bleeding
- D. Fluid resuscitation
Correct answer: D
Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.
3. Which of the following is NOT a physiological role of proteins?
- A. Providing resistance to disease
- B. Regulating fluid balance
- C. Repairing tissue
- D. Serving as the primary source of energy
Correct answer: D
Rationale: Proteins play a diverse range of physiological roles in the body, such as providing resistance to disease, regulating fluid balance, and repairing tissues. However, they are not the primary source of energy for the body. Carbohydrates and fats typically fulfill this role. Therefore, choice D is the correct answer, as it is not a function that proteins perform. Conversely, choices A, B, and C are all physiological functions of proteins, making them incorrect responses to this particular question.
4. During a clinical assessment of a 68-year-old client who has suffered a head injury, a neurologist suspects that the client has sustained damage to her vagus nerve (CN X). Which assessment finding is most likely to lead the physician to this conclusion?
- A. The client has difficulty swallowing.
- B. The client has loss of gag reflex.
- C. The client has an inability to smell.
- D. The client has impaired eye movement.
Correct answer: B
Rationale: The correct answer is B. Damage to the vagus nerve can result in the loss of the gag reflex, which is a key indicator for the neurologist. Difficulty swallowing (Choice A) is more associated with issues related to the glossopharyngeal nerve (CN IX) and hypoglossal nerve (CN XII). An inability to smell (Choice C) is related to the olfactory nerve (CN I), and impaired eye movement (Choice D) is typically associated with damage to the oculomotor nerve (CN III), trochlear nerve (CN IV), or abducens nerve (CN VI), not the vagus nerve.
5. 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: Morphine is the preferred analgesic in sickle cell crisis due to its potency and effectiveness in managing severe pain.