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: Corrected Rationale: 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. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.
2. Which situations are classified as natural disasters?
- A. Blizzards
- B. A, C
- C. Volcanic eruptions
- D. Structural collapse
Correct answer: B
Rationale: The correct answer is B. Blizzards and volcanic eruptions are both examples of natural disasters caused by natural forces such as extreme weather conditions and tectonic activities. On the other hand, structural collapse is typically a result of man-made factors like poor construction or maintenance. Therefore, choices A, C, and D are incorrect as only blizzards and volcanic eruptions are classified as natural disasters.
3. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in a minute
- B. The client diagnosed with coronary artery disease who wants to ambulate
- C. The client diagnosed with mitral valve prolapse with an audible S3
- D. The client diagnosed with pericarditis who is in normal sinus rhythm
Correct answer: C
Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.
4. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?
- A. Encourage the client to drink liquids
- B. Perform active range of motion exercises
- C. Elevate the head of the bed to 45 degrees
- D. Provide a high-fiber diet to the client
Correct answer: B
Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.
5. Participating in the development of long-term and preventive health goals with the patient and their family is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: B
Rationale: The correct answer is B: Planning. In the nursing process, planning involves developing long-term and preventive health goals in collaboration with the patient and their family. This step focuses on outlining the strategies and interventions needed to achieve the desired outcomes. Choice A, Evaluation, occurs after interventions are implemented to assess the effectiveness of the care provided. Choice C, Implementation, involves carrying out the planned interventions. Choice D, Assessment, is the initial step in the nursing process that involves collecting data to identify the patient's needs and health status.
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