ATI RN
ATI RN Custom Exams Set 3
1. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
- A. Assess the client’s vital signs
- B. Start an IV with an 18-gauge needle
- C. Begin iced saline lavage
- D. A, B
Correct answer: D
Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client’s vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.
2. A client with a history of rheumatic fever presents with signs of heart failure. What is the likely underlying cause?
- A. Infective endocarditis
- B. Coronary artery disease
- C. Mitral valve stenosis
- D. Aortic regurgitation
Correct answer: C
Rationale: The correct answer is C: Mitral valve stenosis. Rheumatic fever can lead to scarring and thickening of the heart valves, often affecting the mitral valve. This stenosis can impede blood flow from the left atrium to the left ventricle, eventually causing heart failure. Choice A, infective endocarditis, is an infection of the endocardium, the inner lining of the heart chambers and valves, and is not directly related to rheumatic fever. Choice B, coronary artery disease, involves the obstruction of coronary arteries supplying the heart muscle with blood, leading to ischemia and not typically associated with rheumatic fever. Choice D, aortic regurgitation, is the backflow of blood from the aorta to the left ventricle and is not a common consequence of rheumatic fever.
3. Which of the following conditions is not treated with Dexamethasone?
- A. Inflammation
- B. Asthma
- C. Addison’s disease
- D. Wilson’s disease
Correct answer: D
Rationale: Dexamethasone is not used to treat Wilson’s disease. It is a corticosteroid primarily used for conditions like inflammation, asthma, and Addison’s disease. Wilson’s disease is a genetic disorder involving copper accumulation and is treated with medications like chelating agents or zinc salts, not Dexamethasone.
4. A child diagnosed with a soft tissue tumor is being treated with chemotherapy. Prior to administering the chemotherapy, which laboratory test should the nurse monitor to determine if the child has any capability of fighting infections?
- A. Hemoglobin
- B. Red blood cell count
- C. Platelets
- D. Absolute neutrophil count (ANC)
Correct answer: D
Rationale: The Absolute Neutrophil Count (ANC) is crucial for determining the child's ability to fight infections. Neutrophils play a key role in combating bacterial infections. Monitoring the ANC is essential before administering chemotherapy, as a low ANC indicates an increased risk of infection. Hemoglobin, red blood cell count, and platelets are important for assessing oxygen-carrying capacity, anemia, and clotting function, respectively, but they do not directly reflect the child's capability to fight infections.
5. A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?
- A. 2 hr glucose tolerance test level 150 mg/dL
- B. Fasting blood glucose 70 mg
- C. Glycosylated hemoglobin 5%
- D. Casual blood glucose 90 mg/dL
Correct answer: A
Rationale: A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance.