ATI RN
ATI RN Custom Exams Set 3
1. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?
- A. Deep tendon reflexes
- B. Arterial blood gases
- C. Skin turgor
- D. Capillary refill time
Correct answer: A
Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.
2. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
- A. Assess the client’s vital signs
- B. Start an IV with an 18-gauge needle
- C. Begin iced saline lavage
- D. A, B
Correct answer: D
Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client’s vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.
3. 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.
4. A nurse is reviewing the laboratory results for a client with a history of atherosclerosis and notes elevated cholesterol levels. Which statement by the client indicates the nurse should plan follow-up instruction on a low-cholesterol diet?
- A. ''I take an omega-3 supplement daily.''
- B. ''I cook my food with canola oil.''
- C. ''I eat three eggs for breakfast each morning.''
- D. ''I flavor my meat with lemon juice.''
Correct answer: C
Rationale: The correct answer is C. Eating three eggs daily increases cholesterol intake, which could exacerbate atherosclerosis. Omega-3 supplements, cooking with canola oil, and flavoring meat with lemon juice do not significantly impact cholesterol levels compared to consuming three eggs daily. Therefore, the nurse should focus on educating the client to reduce egg consumption to improve cholesterol levels.
5. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal border
- B. Erb’s point
- C. Second intercostal space, left sternal border
- D. Fourth intercostal space, left sternal border
Correct answer: A
Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.
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