ATI RN
ATI RN Custom Exams Set 1
1. What is the initial step in providing healthcare for a patient?
- A. Obtain and interpret vital signs
- B. Determine the needs of the patient
- C. Develop a plan of care
- D. Obtain lab work and x-rays
Correct answer: B
Rationale: The initial step in providing healthcare for a patient is to determine the needs of the patient. This step involves assessing the patient's condition, listening to their concerns, and understanding what care or treatment they require. Obtaining and interpreting vital signs (Choice A) is a crucial step but typically follows the assessment of the patient's needs. Developing a plan of care (Choice C) and obtaining lab work and x-rays (Choice D) come after understanding the patient's needs and assessing their condition.
2. Identifying the strengths and weaknesses in the nursing care plan is part of which of the following steps in determining and fulfilling the patient's nursing care needs?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: A
Rationale: Correct. Evaluation involves assessing the effectiveness of the nursing care plan by identifying its strengths and weaknesses. This step helps in determining if the plan is meeting the patient's needs. Choice B (Planning) is incorrect because planning involves developing the nursing care plan based on the assessment of the patient's needs. Choice C (Implementation) is incorrect as it refers to putting the nursing care plan into action. Choice D (Assessment) is incorrect as assessment is the initial step in the nursing process, involving data collection and analysis to identify the patient's needs.
3. What is the best position for any procedure that involves vaginal and cervical examination?
- A. Dorsal recumbent
- B. Side lying
- C. Supine
- D. Lithotomy
Correct answer: D
Rationale: The lithotomy position is the most suitable position for procedures involving vaginal and cervical examination because it provides the best access to the vaginal and cervical regions. In this position, the patient lies on their back with their legs flexed and feet placed in stirrups, allowing for optimal visualization and access to the area. This position facilitates proper examination, diagnosis, and treatment when working in the gynecological field. Choices A, B, and C are incorrect as they do not provide the necessary exposure and access required for a thorough vaginal and cervical examination. Dorsal recumbent, side lying, and supine positions may limit visibility and hinder the examination process in such cases.
4. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip prior to initiating the Coumadin
- B. Check the client’s INR prior to beginning Coumadin
- C. Clarify the order with the health care provider as soon as possible
- D. Administer the Coumadin along with the heparin drip as ordered
Correct answer: D
Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.
5. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?
- A. Encouraging family discussion of feelings
- B. Accepting the family’s experience of anger
- C. Facilitating the use of spiritual practices identified by the family
- D. All of the above
Correct answer: D
Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.