ATI RN
ATI RN Custom Exams Set 2
1. The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus?
- A. Roast beef, brown rice, green beans, carrot and raisin salad, and milk
- B. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade
- C. Two scrambled eggs, bacon, white toast with strawberry jam, and coffee
- D. Corn flakes with milk, whole wheat toast, and orange juice
Correct answer: A
Rationale: The correct answer is A. Roast beef is high in heme iron, which is best absorbed and helps treat iron deficiency anemia. Choices B, C, and D do not contain significant sources of iron, especially heme iron, making them less effective in treating iron deficiency anemia.
2. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)
- A. Obtain the pulses in all four extremities
- B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
- C. Determine the client’s orientation to person, place, and time
- D. B, C
Correct answer: D
Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.
3. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?
- A. Presence of thin pink drainage in the Jackson Pratt
- B. Guarding when the nurse touches the abdomen
- C. Tenderness around the surgical site during palpation
- D. Complaints of chills and feeling feverish
Correct answer: D
Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.
4. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
- A. The client with an abdominal aortic aneurysm who is constipated
- B. The client on bed rest who ambulated to the bathroom
- C. The client with essential hypertension who has epistaxis and a headache
- D. The client with arterial occlusive disease who has a decreased pedal pulse
Correct answer: C
Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.
5. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?
- A. 32-year-old with diarrhea for 6 hours
- B. 2-year-old with 1 wet diaper in 24 hours
- C. 40-year-old with abdominal cramping
- D. 10-year-old who is nauseated
Correct answer: B
Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.
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