ATI RN
ATI RN Custom Exams Set 1
1. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:
- A. Astride one of her hips
- B. Strapped in an infant seat
- C. Wrapped tightly in a blanket
- D. Under the arm using a football hold
Correct answer: A
Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.
2. Which of the following questions illustrates the group role of encourager?
- A. What were you saying?
- B. Who wants to respond next?
- C. Where do you go from here?
- D. Why haven’t we heard from you?
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
3. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct answer: No fluctuations in the water seal chamber
Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.
4. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Massage the injection site after administration.
- B. Administer the medication intramuscularly.
- C. Inject the medication into the client's abdomen.
- D. Inject the medication into the deltoid muscle.
Correct answer: C
Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously, not intramuscularly. Massaging the injection site after administration is not recommended as it can cause bruising or discomfort. Injecting the medication into the deltoid muscle is also incorrect because enoxaparin should be given in areas of adipose tissue, such as the abdomen, to ensure proper absorption and effectiveness.
5. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?
- A. Position the client's legs in adduction
- B. Place a pillow between the client's legs when turning
- C. Keep the client in a low Fowler's position
- D. Turn the client onto the affected side
Correct answer: B
Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.