ATI RN
ATI RN Custom Exams Set 5
1. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?
- A. “I should increase fruits, bran, and fluids in my diet.”
- B. “I will use warm compresses and take sitz baths daily.”
- C. “I must take a laxative every night and have a stool daily.”
- D. “I can use an analgesic ointment or suppository for pain.”
Correct answer: C
Rationale: Choice C indicates that further teaching is needed because taking a laxative every night and aiming to have a stool daily can lead to dependence and is not recommended for managing hemorrhoids. Choices A, B, and D are appropriate self-care measures for hemorrhoids, such as increasing fiber intake, using warm compresses/sitz baths, and using analgesic ointments or suppositories for pain relief.
2. A client who experienced a cesarean birth due to dysfunctional labor expresses disappointment for not having a natural childbirth. Which response should the nurse make?
- A. Validate the client's feelings by saying, 'It sounds like you are feeling sad that things didn’t go as planned.'
- B. Assure the client by stating, 'At least you know you have a healthy baby.'
- C. Encourage the client by suggesting, 'Maybe next time you can have a vaginal delivery.'
- D. Provide information by saying, 'You can resume sexual relations sooner than if you had delivered vaginally.'
Correct answer: A: 'It sounds like you are feeling sad that things didn’t go as planned.'
Rationale: The correct response is to acknowledge and validate the client's feelings of disappointment. This empathetic approach demonstrates understanding and support for the client's emotional state, fostering a therapeutic nurse-client relationship. Options B, C, and D do not address the client's emotional needs or provide appropriate support in this situation.
3. Why does the nurse have a 2-year-old boy sit in a “tailor” position while palpating for the presence of the testes?
- A. It prevents the cremasteric reflex
- B. Undescended testes can be palpated
- C. The child has an inguinal hernia
- D. The child does not yet have a need for privacy
Correct answer: A
Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.
4. Which of the following organs are primarily affected by poorly managed hypertension?
- A. The bladder and urethra
- B. The brain and skin
- C. The heart and kidneys
- D. The stomach and intestines
Correct answer: C
Rationale: Poorly managed hypertension primarily affects the heart and kidneys. The heart is at risk of conditions like heart failure due to the increased workload from elevated blood pressure. The kidneys can suffer damage from longstanding hypertension, leading to kidney disease. Choices A, B, and D are incorrect because the bladder, urethra, brain, skin, stomach, and intestines are not the primary organs affected by poorly managed hypertension.
5. A nurse is preparing to administer medications to a client who has a nasogastric (NG) tube. Which of the following actions should the nurse take first?
- A. Check for tube placement.
- B. Flush the NG tube with 0.9% sodium chloride.
- C. Administer the medications as a bolus.
- D. Dissolve the medications in 30 mL of sterile water.
Correct answer: A
Rationale: The correct first action for the nurse to take when preparing to administer medications to a client with a nasogastric (NG) tube is to check for tube placement. This step is crucial to ensure that the NG tube is correctly positioned in the stomach and not in the respiratory tract, reducing the risk of aspiration. Flushing the NG tube with 0.9% sodium chloride, administering the medications as a bolus, or dissolving the medications in sterile water should only be done after confirming the proper placement of the NG tube. Therefore, options B, C, and D are incorrect as they precede the essential step of verifying tube placement.