ATI RN
ATI RN Custom Exams Set 4
1. 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.
2. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
- A. Hydrocolloid
- B. Transparent
- C. Gauze
- D. Alginate
Correct answer: A
Rationale: The correct answer is A: Hydrocolloid. For a stage 2 pressure injury, a hydrocolloid dressing is recommended. Hydrocolloid dressings provide a moist environment that promotes healing and is effective for wounds with moderate exudate. Choice B (Transparent) is not typically used for stage 2 pressure injuries as it is more suitable for superficial wounds. Choice C (Gauze) is not ideal for stage 2 pressure injuries as it can adhere to the wound bed and cause trauma upon removal. Choice D (Alginate) is more appropriate for wounds with heavy exudate, not typically seen in stage 2 pressure injuries.
3. The public health RN is working with a client who desires to quit smoking. The client says to the RN, 'I want to quit but I just don't think I have it in me to really make it happen.' According to the Health Belief Model, this response relates to which factor:
- A. Susceptibility
- B. Self-efficacy
- C. Severity
- D. Cue to action
Correct answer: B
Rationale: The correct answer is B, 'Self-efficacy.' In the Health Belief Model, self-efficacy refers to a person's belief in their capacity to execute behaviors necessary to achieve specific goals or outcomes. In this scenario, the client's statement reflects a lack of confidence in their ability to successfully quit smoking, indicating low self-efficacy. By addressing and enhancing the client's self-efficacy, the public health RN can help empower the client to take steps towards successful smoking cessation.
4. During the detoxification stage, it is a priority for the nurse to:
- A. teach skills to recognize and respond to health threatening situations
- B. increase the client’s awareness of unsatisfactory protective behaviors
- C. implement behavior modification
- D. promote homeostasis and minimize the client’s withdrawal symptoms
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct answer: D
Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.