ATI RN
ATI Leadership
1. In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. When a client has a latex allergy, it is crucial to avoid direct contact with latex-containing products to prevent an allergic reaction. Choosing hypoallergenic latex gloves that are powder-free reduces the risk of the client being exposed to latex allergens. Option A is incorrect because using ethylene oxide for sterilization does not directly address the client's latex allergy. Option C is incorrect because cleansing latex ports with chlorhexidine does not eliminate the risk of latex exposure. Option D is incorrect as it does not specifically address the issue of latex allergy during the procedure.
2. A nurse is caring for an immobile client. What is the priority assessment in this client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct answer: Auscultation of lung sounds
Rationale:
3. A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?
- A. Urine specific gravity of 1.045
- B. Sodium level of 155
- C. Blood glucose level of 45
- D. Urine output of 35 ml per hour
Correct answer: B
Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.
4. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the healthcare provider.
- D. Do nothing, as no harm has occurred.
Correct answer: C
Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.
5. A client has a new prescription for Ranitidine. Which of the following instructions should the nurse include?
- A. Take the medication with an antacid.
- B. Avoid drinking coffee while taking this medication.
- C. Take the medication at bedtime.
- D. Stop the medication if you develop a headache.
Correct answer: C
Rationale: The correct instruction for a client prescribed Ranitidine is to take the medication at bedtime. Ranitidine is best taken at night to reduce nighttime stomach acid production, providing optimal relief for conditions like gastroesophageal reflux disease (GERD) and ulcers.
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