a nurse overhears two assistive personnel ap discussing a client in an elevator what action should the nurse take a nurse overhears two assistive personnel ap discussing a client in an elevator what action should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse overhears two assistive personnel (AP) discussing a client in an elevator. What action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This is important because discussing a client's information violates confidentiality policies. Contacting the client's family (Choice A) is not appropriate as it may breach confidentiality further. Notifying the client's provider (Choice B) is not the initial action to take in this situation, as addressing it within the facility should come first. Filing a complaint with the facility's ethics committee (Choice C) is not the immediate step and might not directly address the issue at hand.

2. The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis?

Correct answer: A positive rheumatoid factor

Rationale:

3. Most adults with human immunodeficiency virus will exhibit which of the following laboratory values?

Correct answer: Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal

Rationale:

4. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

5. A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.

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