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

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?

A. Insert an indwelling urinary catheter
B. Apply fetal heart rate monitor
C. Initiate fundal massage
D. Initiate an oxytocin IV infusion

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. When teaching a client about nutritional intake, what should be included?

A. Carbohydrates should be at least 45% of your caloric intake.
B. Protein should be at least 55% of your caloric intake.
C. Carbohydrates should be at least 30% of your caloric intake.
D. Protein should be at least 60% of your caloric intake.

Correct answer: A

Rationale: When educating a client about nutritional intake, it is important to mention that carbohydrates should constitute at least 45% of their daily caloric intake for a balanced diet. This macronutrient provides energy and is essential for proper bodily functions. Choice B is incorrect because protein should typically account for around 10-35% of total caloric intake, not 55%. Choice C is too low for the recommended carbohydrate intake, as it should be higher at 45%. Choice D is incorrect as protein intake should generally be around 10-35% of total caloric intake, not 60%.

3. A client expresses fear of surgery. Which response should the nurse make?

A. Explain the risks of the surgery in detail.
B. Tell the client that many clients feel anxious before surgery.
C. Reassure the client that the surgical team is highly experienced.
D. Acknowledge the client's feelings and ask open-ended questions.

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

4. What is the most important assessment for a patient with respiratory distress?

A. Monitor oxygen saturation
B. Check for abnormal breath sounds
C. Check for pitting edema
D. Perform a neurological exam

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

5. A nurse is teaching a client who has chronic kidney disease about managing protein intake. Which of the following statements should the nurse include in the teaching?

A. You should consume more plant-based protein.
B. You should increase your intake of animal protein.
C. You should increase your intake of high-protein foods.
D. You should limit your intake of high-protein foods.

Correct answer: D

Rationale: The correct answer is D: "You should limit your intake of high-protein foods." Clients with chronic kidney disease should reduce their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Choices A, B, and C are incorrect because increasing intake of either plant-based or animal protein or high-protein foods can exacerbate kidney issues in individuals with chronic kidney disease.