ATI RN
ATI RN Custom Exams Set 5
1. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?
- A. The client who needs both sequential compression devices removed
- B. The elderly woman who needs assistance ambulating to the bathroom
- C. The surgical client who needs help changing the gown after bathing
- D. The male client who needs the intravenous fluid discontinued
Correct answer: A
Rationale: The correct answer is A. Removing sequential compression devices could increase the risk of thromboembolism, which is a serious complication. Therefore, this client should be seen first to prevent any potential harm. Choice B may be important, but it does not pose an immediate risk compared to thromboembolism. Choice C is a routine care task that can be delayed, and Choice D, discontinuing intravenous fluid, is important but not as urgent as preventing thromboembolism.
2. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
- A. Collect early in the morning, First voided specimen
- B. Do perineal care before specimen collection
- C. Collect 5 to 10 ml for urine
- D. Discard the first flow of the urine
Correct answer: A
Rationale: When collecting a mid-stream clean catch urine specimen for urine analysis, it is important to collect an adequate amount of urine for accurate testing. A volume of 30 to 60 ml is usually recommended for optimal results, so collecting only 5 to 10 ml would not provide enough urine for testing purposes. It is essential to follow proper collection techniques to ensure accurate and reliable test results.
3. A patient with chronic renal failure should avoid which of the following?
- A. Potassium
- B. Calcium
- C. Iron
- D. Zinc
Correct answer: A
Rationale: Patients with chronic renal failure should avoid potassium due to impaired kidney function. The kidneys may not effectively filter excess potassium from the blood, leading to hyperkalemia. Calcium, iron, and zinc do not need to be avoided specifically in chronic renal failure unless there are other underlying reasons or complications.
4. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
- A. The client will void a minimum of 30 mL per hour
- B. The client will have elastic skin turgor
- C. The client will have no adventitious breath sounds
- D. The client will have a serum creatinine of 1.4 mg/dL
Correct answer: C
Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.
5. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?
- A. “Has your child had any sore throats?”
- B. “Has your child been eating properly?”
- C. “Is your child allergic to any antibiotics?”
- D. “Has your child been exposed to any infections?”
Correct answer: C
Rationale: The correct question for the nurse to ask the mother before administering the MMR vaccine to a 15-month-old is about the child's allergy to antibiotics. This is crucial because the MMR vaccine contains neomycin, an antibiotic, and being allergic to antibiotics like neomycin is a contraindication for the MMR vaccine. Asking about sore throats, eating habits, or exposure to infections is not directly relevant to the administration of the MMR vaccine.