ATI RN
ATI RN Custom Exams Set 5
1. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?
- A. The assistant is putting the stockings on while the client is in the chair.
- B. The assistant inserted two (2) fingers under the proximal end of the stocking.
- C. The assistant elevated the feet while lying down to put on the stockings.
- D. The assistant made sure the toes were warm after putting the stockings on.
Correct answer: A
Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.
2. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
- A. iron.
- B. folic acid.
- C. cobalamin (vitamin B12).
- D. ascorbic acid (vitamin C).
Correct answer: C
Rationale: The correct answer is C: cobalamin (vitamin B12). Methotrexate can lead to a deficiency in cobalamin, resulting in megaloblastic anemia. Therefore, increasing the oral intake of cobalamin is essential to address this deficiency. Choice A, iron, is incorrect because megaloblastic anemia caused by methotrexate is not typically due to iron deficiency. Choice B, folic acid, is also incorrect as methotrexate does not directly cause folic acid deficiency. Choice D, ascorbic acid (vitamin C), is incorrect as it is not directly related to megaloblastic anemia caused by methotrexate; instead, cobalamin is the key vitamin that needs attention.
3. How many drops are equivalent to 1 tsp?
- A. 15
- B. 60
- C. 10
- D. 30
Correct answer: B
Rationale: 1 teaspoon (tsp) is equivalent to approximately 60 drops. Drops and teaspoons vary in volume and size, affecting the conversion ratio. Choice A (15 drops) is incorrect as it's a common misconception. Choice C (10 drops) and Choice D (30 drops) do not align with the standard conversion of 1 tsp to 60 drops.
4. A healthcare professional is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
- A. Airborne
- B. Protective environment
- C. Contact
- D. Droplet
Correct answer: B
Rationale: The correct answer is 'B: Protective environment.' Rubella requires placing the client in a protective environment due to its airborne precautions. Airborne precautions are typically used for diseases that are spread through tiny droplets that remain in the air for an extended period, like tuberculosis. Contact precautions are used for diseases that are spread by direct or indirect contact, such as MRSA. Droplet precautions are implemented for diseases transmitted through respiratory droplets, like influenza. Therefore, in the case of rubella, airborne precautions in a protective environment are necessary.
5. The nurse is administering nitroglycerin IV to a client with chest pain. What is the most important parameter to monitor?
- A. Blood pressure
- B. Heart rate
- C. Oxygen saturation
- D. Respiratory rate
Correct answer: A
Rationale: The correct answer is A: Blood pressure. When administering nitroglycerin IV to a client with chest pain, monitoring blood pressure is crucial as nitroglycerin can cause significant hypotension. While heart rate, oxygen saturation, and respiratory rate are important parameters to assess, blood pressure takes precedence in this scenario due to the potential hypotensive effects of nitroglycerin.