ATI RN
ATI RN Custom Exams Set 3
1. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?
- A. At the client's back
- B. At the client's right side
- C. At the client's left side
- D. In front of a sitting client
Correct answer: D
Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.
2. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?
- A. Explain to the client that it is too early to have an injection for pain
- B. Call the practitioner, report the client’s symptoms, and obtain further orders
- C. Reposition the client for greater comfort and turn on the television as a distraction
- D. Prepare the injection and administer it to the client early because of the severe pain
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to call the practitioner, report the client’s symptoms, and obtain further orders. The client's symptoms, including severe abdominal pain, pallor, perspiration, thready rapid pulse, and feeling faint, are indicative of potential complications like internal bleeding, which require immediate medical evaluation. Explaining to the client that it is too early for pain medication or repositioning the client for comfort are not appropriate actions given the severity of the symptoms. Administering the injection early without consulting the practitioner can be dangerous and may worsen the client's condition.
3. Which question should the healthcare provider ask when assessing the client for an endocrine dysfunction?
- A. “Have you noticed any pain in your legs when walking?”
- B. “Have you had any unexplained weight loss?”
- C. “Have you noticed any change in your bowel movements?”
- D. “Have you experienced any joint pain or discomfort?”
Correct answer: B
Rationale: The correct answer is B: “Have you had any unexplained weight loss?” Unexplained weight loss can be a significant symptom of various endocrine disorders, such as hyperthyroidism and diabetes. Weight changes are often closely linked to endocrine dysfunction due to the hormonal imbalances affecting metabolism. Choices A, C, and D are less specific to endocrine dysfunction. Pain in the legs, changes in bowel movements, and joint pain or discomfort are symptoms that can be related to various health conditions but are not as indicative of endocrine disorders as unexplained weight loss.
4. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease?
- A. Discuss the importance of tapering medications when discontinuing medication
- B. Explain that the dose will need to be decreased during times of stress or infection
- C. Instruct the client to take medication on an empty stomach with a glass of water
- D. Encourage the client to wear a MedicAlert bracelet and carry a card in the wallet
Correct answer: A
Rationale: The correct answer is A because tapering glucocorticoids is crucial to prevent adrenal insufficiency, which can occur if the medication is stopped abruptly. Choice B is incorrect as it refers to dose adjustments during stress or infection, not discontinuation. Choice C is incorrect because it does not specifically address the issue of stopping the medication. Choice D is not directly related to the management of glucocorticoid therapy for Addison’s disease.
5. AND Answers
- A. The nurse scoop the specimen specifically at the site
- B. She took around 1 inch of specimen or a teaspoonful
- C. Ask the client to call her for the specimen after the
- D. Ask the client to defecate in a bedpan, Secure a
Correct answer: B
Rationale: When collecting a stool specimen, the nurse should usually take about 1 inch of the specimen or a teaspoonful for testing purposes. This amount is sufficient for laboratory analysis and helps ensure accurate results. It is important for the nurse to follow the proper procedure for specimen collection to maintain accuracy in diagnostic testing.