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 is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish a rapport with the client to decrease embarrassment during site assessment
- B. Encourage the client to lie in the lithotomy position twice a day
- C. Milk the tube inserted during surgery to facilitate the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood
Correct answer: A
Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.
3. What intervention would be most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing daily at the same time
- C. Monitor the client’s medication levels daily
- D. Monitor the percentage of each meal eaten
Correct answer: A
Rationale: The correct answer is A: Assess the intravenous fluids for rate and volume. After a nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Choice B is incorrect because changing the surgical dressing daily is important but not the most critical intervention. Choice C is incorrect as monitoring medication levels daily may be necessary but is not the priority after a nephrectomy. Choice D is irrelevant to the immediate postoperative care needed after a nephrectomy.
4. Where do most peptic ulcers occur?
- A. Esophagus
- B. Stomach
- C. Duodenum
- D. Jejunum
Correct answer: C
Rationale: Most peptic ulcers occur in the duodenum, particularly in cases of duodenal ulcers. Peptic ulcers are most commonly found in the duodenum or the first part of the small intestine. While ulcers can also occur in the esophagus and stomach, they are predominantly located in the duodenum. Therefore, options A, B, and D are incorrect.
5. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?
- A. Hold the medication
- B. Administer the digoxin
- C. Notify the healthcare provider
- D. Recheck the apical rate in 1 hour
Correct answer: B
Rationale: The correct answer is to administer the digoxin. An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly prescribed for heart failure in newborns to help improve cardiac function. Holding the medication or notifying the healthcare provider is not necessary as the heart rate is normal for a newborn. Rechecking the apical rate in 1 hour is not needed since the heart rate is within the expected range.