ATI RN
ATI RN Custom Exams Set 2
1. What intervention should the nurse implement for the client who has an ileal conduit?
- A. Pouch the stoma with a one-inch margin around the stoma
- B. Refer the client to the United Ostomy Association for discharge teaching
- C. Report to the healthcare provider any decrease in urinary output
- D. Monitor the stoma for signs and symptoms of infection every shift
Correct answer: C
Rationale: The correct intervention for a client with an ileal conduit is to report any decrease in urinary output to the healthcare provider. Decreased urinary output in these clients may indicate a blockage or another complication, which requires immediate attention. Monitoring the stoma for signs of infection (Choice D) is important but not the priority when compared to a decrease in urinary output. Pouching the stoma with a one-inch margin around it (Choice A) is incorrect as it does not address the issue of decreased urinary output. Referring the client to the United Ostomy Association (Choice B) is not necessary in this immediate situation where a potential complication is suspected.
2. To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What does the nurse do next?
- A. Clamp another section of the tube to create a fixed sample section for retrieval.
- B. Insert a syringe into the injection port and aspirate the quantity of urine required.
- C. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
- D. Withdraw 10 mL of urine and discard it; then withdraw 10 mL more for the sample.
Correct answer: Clean the injection port cap of the drainage tubing with povidone-iodine solution
Rationale: After clamping the drainage tubing, the next step in obtaining a sterile urine specimen from a client with a Foley catheter is to clean the injection port cap of the drainage tubing with povidone-iodine solution. This cleaning step helps prevent contamination of the urine sample. Clamping another section of the tube isn't necessary and may not be a standard practice. Inserting a syringe into the injection port to aspirate urine isn't the correct step at this point. Withdrawing 10 mL of urine and discarding it before collecting the sample isn't appropriate and may lead to an inaccurate sample.
3. Each statement is true of water-soluble vitamins, except one. Which is it?
- A. Act as coenzymes
- B. Deficiencies develop rapidly
- C. Daily intake is necessary
- D. Absorbed in the jejunum
Correct answer: B
Rationale: The correct answer is B. Water-soluble vitamins do not develop deficiencies rapidly because the body does not store them for long periods. They must be obtained through food constantly. Choice A is correct because water-soluble vitamins often act as coenzymes in various metabolic reactions. Choice C is correct as daily intake of water-soluble vitamins is necessary since they are not stored in the body. Choice D is incorrect as water-soluble vitamins are absorbed primarily in the small intestine, particularly in the duodenum and ileum, not the jejunum.
4. How should fluid balance be monitored in a patient receiving diuretics?
- A. Monitor daily weight
- B. Monitor intake and output
- C. Check for edema
- D. Monitor blood pressure
Correct answer: A
Rationale: Corrected Question: To assess fluid balance in a patient receiving diuretics, monitoring daily weight is the most accurate method. This is because diuretics primarily affect fluid levels in the body, leading to changes in weight due to fluid loss. While monitoring intake and output, checking for edema, and monitoring blood pressure are important aspects of patient care, they do not provide as direct and accurate information about fluid balance as daily weight monitoring specifically in patients on diuretics.
5. In the last weeks of pregnancy, __________.
- A. the fetus usually loses weight
- B. most fetuses assume an upside-down position
- C. fetal growth increases dramatically
- D. the fetus relies on its own well-developed immune system
Correct answer: B
Rationale: In the last weeks of pregnancy, most fetuses assume an upside-down position known as the head-down position or vertex presentation. This position is ideal for a smoother labor and delivery process as it helps the baby move through the birth canal. Fetal growth has already slowed down at this stage, so option C is incorrect. Option A is inaccurate as the fetus typically gains weight in the final weeks. Option D is incorrect because the fetus relies on the mother's immune system while in the womb.