ATI RN
ATI Leadership Practice B
1. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
- A. Give the patient 4 to 6 oz more orange juice.
- B. Administer the PRN glucagon (Glucagon) 1 mg IM.
- C. Have the patient eat some peanut butter with crackers.
- D. Notify the healthcare provider about the hypoglycemia.
Correct answer: A
Rationale: The correct action for the nurse to take next is to give the patient 4 to 6 oz more orange juice. The patient's blood glucose has increased from 62 mg/dL to 67 mg/dL after consuming the initial 4 oz of orange juice, indicating that the treatment is effective. Providing additional orange juice will help further raise the blood glucose levels. Administering glucagon (Choice B) is not necessary as the patient's blood glucose is already rising. Having the patient eat peanut butter with crackers (Choice C) is a slower-acting option compared to orange juice. Notifying the healthcare provider about the hypoglycemia (Choice D) is not needed at this point since the patient's blood glucose is improving.
2. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?
- A. Confront the nurse about the behavior.
- B. Notify the hospital's safety committee.
- C. Document the observation without addressing it.
- D. Follow up with the nurse at a later time.
Correct answer: B
Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.
3. The child is admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?
- A. Place the child in the Trendelenburg position.
- B. Apply moist heat to the abdomen.
- C. Allow the child to assume a position of comfort.
- D. Administer a saline enema to cleanse the bowel.
Correct answer: C
Rationale: Allowing the child to assume a position of comfort is appropriate as it helps alleviate discomfort without the risk of complications. Placing the child in the Trendelenburg position could increase intra-abdominal pressure and worsen the condition. Applying moist heat may lead to vasodilation and potential perforation in case of appendicitis. Administering a saline enema can be harmful if the appendix is inflamed or perforated.
4. A nurse is caring for a client who has a new prescription for a low-sodium diet. The client’s family has requested to bring in some of the client’s favorite foods. Which of the following food items should the nurse tell the family members to omit?
- A. Boiled rice
- B. Flat bread
- C. Broiled fish fillet
- D. Pickled vegetables
Correct answer: Pickled vegetables
Rationale: The correct answer is 'Pickled vegetables.' Pickled vegetables are high in sodium due to the pickling process, making them unsuitable for a low-sodium diet. Boiled rice, flat bread, and broiled fish fillet are generally lower in sodium compared to pickled vegetables and can be included in a low-sodium diet. Therefore, the nurse should advise the family to omit pickled vegetables to adhere to the client's dietary restrictions.
5. What is the primary action when caring for a patient with a stage 3 pressure ulcer?
- A. Apply a hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Apply moist gauze to the ulcer
Correct answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.
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