a charge nurse is teaching a group of newly licensed nurses about the correct use of restraints which of the following should the nurse include in the
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.

2. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.

3. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

4. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.

5. A client at 32 weeks of gestation with preeclampsia is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because swelling in the hands is a potential sign of worsening preeclampsia, and the client should report this to their provider. Choice A is incorrect since aspirin is not recommended in preeclampsia. Choice C is incorrect as calcium intake is not directly related to preventing seizures in preeclampsia. Choice D is incorrect because protein restriction is not the standard management for preventing further kidney damage in preeclampsia.

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