ATI RN
ATI RN Custom Exams Set 2
1. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?
- A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
- B. Give two rescue breaths
- C. Look, listen, and feel for breathing
- D. Begin chest compressions
Correct answer: A
Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.
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. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?
- A. All of the above
- B. “My abdominal muscles may be tender because of the procedure.”
- C. “My diet should be light at first, and then I can progress to a regular diet.”
- D. “It is normal to feel gassy or bloated for a short while after the procedure.”
Correct answer: A
Rationale: The correct answer is A: "All of the above." Evaluation of learning after a colonoscopy would be evident if the client mentions all the statements provided. Mild tenderness in the abdominal muscles, starting with a light diet and progressing to a regular diet, and experiencing gas or bloating temporarily are all expected after a colonoscopy. Therefore, all the statements are correct in demonstrating the client's understanding of the post-procedure instructions. Choices B, C, and D provide accurate information about the expected outcomes following a colonoscopy, making them incorrect answers individually but correct when combined as option A.
4. A client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the healthcare provider ordering?
- A. Paracentesis
- B. Chest tube insertion
- C. Lumbar puncture
- D. Biopsy of the pancreas
Correct answer: B
Rationale: The correct answer is B: Chest tube insertion. A chest tube may be needed if a pancreatic pseudocyst ruptures into the pleural space, causing a pleural effusion. Paracentesis (choice A) involves the removal of fluid from the abdominal cavity, not typically indicated for a pancreatic pseudocyst. Lumbar puncture (choice C) is a procedure to collect cerebrospinal fluid from the spinal canal, not relevant to a pancreatic pseudocyst. Biopsy of the pancreas (choice D) is a diagnostic procedure to obtain tissue samples for examination and is not typically done in the context of a ruptured pseudocyst.
5. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?
- A. Bone marrow transplant
- B. Splenectomy
- C. Frequent blood transfusions
- D. Liver biopsy
Correct answer: B
Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis as it helps prevent hemolysis and improve anemia. Removing the spleen reduces the destruction of the abnormal red blood cells. Choice A, Bone marrow transplant, is not a standard treatment for hereditary spherocytosis. Choice C, Frequent blood transfusions, may be used to manage anemia in some cases but is not the primary treatment for hereditary spherocytosis. Choice D, Liver biopsy, is not a treatment for hereditary spherocytosis; it is a procedure used to diagnose liver conditions, not related to this hematologic disorder.
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