ATI RN
ATI RN Custom Exams Set 1
1. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client’s BP is 110/70
- B. The client’s potassium level is 3.4 mEq/L
- C. The client has a barky cough
- D. The client’s apical pulse is 56
Correct answer: D
Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.
2. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?
- A. 32-year-old with diarrhea for 6 hours
- B. 2-year-old with 1 wet diaper in 24 hours
- C. 40-year-old with abdominal cramping
- D. 10-year-old who is nauseated
Correct answer: B
Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.
3. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals
- B. Explain the need to decrease intake of flatus-forming foods
- C. Teach the client how to perform gentle perianal care
- D. Encourage the client to see a psychologist
Correct answer: B
Rationale: The correct answer is B. Decreasing the intake of flatus-forming foods can help reduce symptoms of bloating and discomfort in IBS. This intervention focuses on dietary modifications that can positively impact the client's condition. Instructing the client to avoid drinking fluids with meals (choice A) may not directly address the underlying cause of IBS symptoms. Teaching perianal care (choice C) is important for hygiene but does not directly address IBS symptoms. Encouraging the client to see a psychologist (choice D) may be beneficial for managing stress or anxiety associated with IBS but does not directly target symptom reduction through dietary changes.
4. The nurse is caring for a client recovering from intestinal surgery. Which assessment finding would require immediate intervention?
- A. Presence of thin pink drainage in the Jackson Pratt drain
- B. Guarding when the nurse touches the abdomen
- C. Tenderness around the surgical site during palpation
- D. Complaints of chills and feeling feverish
Correct answer: D
Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.
5. After undergoing a pericardiocentesis, which interventions should the nurse implement?
- A. Monitor vital signs every 15 minutes for the first hour
- B. Evaluate the client’s cardiac rhythm
- C. Record the amount of fluid removed as output
- D. All of the above
Correct answer: D
Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.