ATI RN
ATI RN Custom Exams Set 3
1. When palpating the client's neck for lymphadenopathy, where should the nurse position herself?
- 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 herself 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. Placing oneself 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 as positioning at the back or sides of the client may hinder proper assessment due to limited visibility and access to the neck area.
2. Which of the following statements does NOT apply to a nursing plan of care?
- A. It contains short-term goals
- B. It is developed by the patient's physician
- C. It must be continually evaluated
- D. It contains long-range goals
Correct answer: B
Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.
3. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?
- A. Discontinue the use of steroid therapy immediately if symptoms develop.
- B. Take diuretics as needed to treat the dependent edema in ankles.
- C. Increase the intake of dietary sodium every day to decrease fluid retention.
- D. Report any decrease in daily weight during treatment to the healthcare provider.
Correct answer: D
Rationale: The correct intervention for the nurse to include in the care plan for a client diagnosed with nephritic syndrome is to instruct the client to report any decrease in daily weight during treatment to the healthcare provider. A decrease in weight could indicate worsening of the nephritic syndrome or dehydration, making it crucial information for the healthcare provider to assess the client's condition. Option A is incorrect because discontinuing steroid therapy should be done under medical guidance rather than immediately if symptoms develop. Option B is incorrect because diuretics should not be taken without healthcare provider's guidance due to the risk of electrolyte imbalances. Option C is incorrect as increasing dietary sodium would exacerbate fluid retention, which is undesirable in nephritic syndrome.
4. Why may patients with hiatal hernia develop anemia?
- A. Iron absorption is reduced
- B. Gastritis may cause bleeding
- C. Iron stores turn over more quickly
- D. Patients have an aversion to foods that are good sources of iron
Correct answer: B
Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can lead to gastrointestinal bleeding, resulting in anemia due to blood loss. Choice A is incorrect because hiatal hernia does not directly affect iron absorption. Choice C is incorrect as iron stores turning over more quickly is not a typical reason for anemia in hiatal hernia patients. Choice D is incorrect as an aversion to iron-rich foods does not directly cause anemia in this context.
5. In patients receiving chemotherapy, which nutrient is often supplemented to manage mucositis?
- A. Vitamin E
- B. Vitamin B12
- C. Zinc
- D. Calcium
Correct answer: C
Rationale: Zinc supplementation is often recommended to manage mucositis in patients undergoing chemotherapy. Zinc plays a crucial role in wound healing and immune function, which can help alleviate the symptoms of mucositis. Vitamin E (Choice A) is known for its antioxidant properties but is not typically used to manage mucositis. Vitamin B12 (Choice B) is important for red blood cell production and nerve function but is not directly associated with mucositis management. Calcium (Choice D) is essential for bone health and muscle function but is not a primary nutrient supplemented to manage mucositis.
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