ATI RN
ATI RN Custom Exams Set 4
1. After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse’s first priority?
- A. Establish a rapport to foster trust
- B. Place the client in full restraints
- C. Try to communicate with the client in writing
- D. Ensure safety by initiating suicide precautions
Correct answer: D
Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.
2. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?
- A. Measuring and recording fluid intake and output
- B. Weighing the client daily at the same time each day
- C. Assessing the client’s vital signs every 4 hours
- D. Checking the client’s lungs for crackles during every shift
Correct answer: B
Rationale: Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can reflect fluid retention or loss. Measuring and recording fluid intake and output (Choice A) is important but may not provide immediate changes in fluid status. Assessing vital signs (Choice C) can offer some information but may not be as specific to fluid status as daily weighing. Checking the client's lungs for crackles (Choice D) is more related to assessing respiratory status rather than direct fluid monitoring.
3. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?
- A. Secure a clean container
- B. Discard the container if the outside becomes dirty
- C. Rinse the client's mouth with Listerine before collection
- D. Tell the client that 4 tablespoons of sputum are needed
Correct answer: A
Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.
4. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease?
- A. Discuss the importance of tapering medications when discontinuing medication
- B. Explain that the dose will need to be decreased during times of stress or infection
- C. Instruct the client to take medication on an empty stomach with a glass of water
- D. Encourage the client to wear a MedicAlert bracelet and carry a card in the wallet
Correct answer: A
Rationale: The correct answer is A because tapering glucocorticoids is crucial to prevent adrenal insufficiency, which can occur if the medication is stopped abruptly. Choice B is incorrect as it refers to dose adjustments during stress or infection, not discontinuation. Choice C is incorrect because it does not specifically address the issue of stopping the medication. Choice D is not directly related to the management of glucocorticoid therapy for Addison’s disease.
5. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?
- A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
- B. Give two rescue breaths
- C. Look, listen, and feel for breathing
- D. Begin chest compressions
Correct answer: A
Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.