a nurse is caring for a client who is in active labor and has ruptured membranes which action should the nurse take

ATI RN

ATI Comprehensive Exit Exam

1. A client in active labor has ruptured membranes. What action should the nurse take?

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

Correct answer: A

Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.

2. What is the best intervention for a patient with respiratory distress?

A. Administer oxygen
B. Administer bronchodilators
C. Administer IV fluids
D. Administer corticosteroids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

3. 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%.

4. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

A. Soak your feet in warm water every day to prevent dryness.
B. Wear cotton socks to keep your feet dry.
C. Apply lotion between your toes after bathing.
D. Cut your toenails in a rounded shape.

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Wear cotton socks to keep your feet dry.' This is essential in diabetes mellitus as moisture can lead to infections. Choice A is incorrect as soaking feet in warm water can actually cause dryness and skin breakdown, which is harmful in diabetes. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect as cutting toenails in a rounded shape can lead to ingrown toenails; clients with diabetes should cut their nails straight across to prevent complications.

5. A nurse is assessing a client who has a new diagnosis of diabetes mellitus. Which of the following findings should the nurse expect?

A. Increased urinary output.
B. Weight gain.
C. Blurred vision.
D. Diaphoresis.

Correct answer: A

Rationale: Increased urinary output is a common finding in clients with diabetes mellitus due to hyperglycemia and osmotic diuresis. This results in the body trying to eliminate excess glucose through urine, leading to increased urinary frequency and volume. Weight gain is not typically associated with diabetes mellitus but may occur in poorly controlled cases due to increased calorie intake. Blurred vision is more commonly associated with acute complications like hyperglycemia or hypoglycemia. Diaphoresis, or excessive sweating, is not a typical finding in diabetes mellitus but can be seen in conditions like hypoglycemia.