a nurse is caring for a client who is at 38 weeks gestation is in active labor and has ruptured membranes which of the following actions should the nu
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Applying a fetal heart rate monitor is the priority action in this scenario as it helps assess the well-being of the fetus during labor. This monitoring is crucial to detect any signs of fetal distress and guide interventions. Inserting an indwelling urinary catheter (Choice A) is not a priority at this time unless there are specific indications. Initiating fundal massage (Choice C) is not necessary in this situation as the focus should be on fetal assessment. Initiating an oxytocin IV infusion (Choice D) is not indicated until the stage of labor and the progress of labor are determined.

2. A nurse is providing teaching to a client who has osteoporosis. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B. Walking regularly is beneficial for clients with osteoporosis as it helps maintain bone density and prevent fractures. Choice A is not the most appropriate because clients with osteoporosis often require more than just calcium supplements. Choice C is incorrect as weight-bearing exercises actually help strengthen bones. Choice D is important, but walking regularly has a more direct impact on bone health in clients with osteoporosis.

3. A nurse is providing dietary teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: Clients taking warfarin should avoid foods high in vitamin K, as it can interfere with the effectiveness of the medication.

4. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

5. How should a healthcare professional educate a patient on the use of an incentive spirometer?

Correct answer: D

Rationale: Instructing the patient to use the spirometer every hour is crucial for optimal lung expansion and to prevent postoperative pulmonary complications. This regular use helps to keep the lungs clear and maintain their capacity. Choices A, B, and C are incorrect because deep breathing, forceful coughing, and blowing into the spirometer do not specifically address the proper use of the incentive spirometer, which is essential for postoperative respiratory recovery.

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