a nurse is reviewing the monitor tracing of a client in labor and notes late decelerations which of the following interventions should the nurse perfo
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

2. A client has a new prescription for metformin. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction the nurse should include for a client prescribed metformin is to avoid drinking alcohol. Alcohol consumption while on metformin increases the risk of lactic acidosis, a serious condition. Taking metformin at bedtime (choice A) is not a standard instruction. Eating 3 large meals each day (choice C) is not specific to metformin use and may not be suitable for all individuals. Reporting muscle pain (choice D) is important but not directly related to metformin use.

3. What is the initial intervention for a patient experiencing an allergic reaction?

Correct answer: A

Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.

4. A nurse is caring for a client who has a new prescription for enalapril. Which of the following findings should the nurse identify as an adverse effect of the medication?

Correct answer: A

Rationale: Corrected Rationale: A persistent cough is a known adverse effect of enalapril, an ACE inhibitor. Enalapril can cause the accumulation of bradykinin, leading to a dry, persistent cough in some patients. Dry mouth (choice B) and urinary retention (choice C) are not typically associated with enalapril use. Insomnia (choice D) is also not a common adverse effect of enalapril. Therefore, the correct answer is A.

5. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: Polyuria is the correct answer. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination (polyuria) and thirst. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. While dehydration from the excessive urination can lead to hypotension rather than hypertension, and weight loss can occur due to fluid loss, the most specific and significant finding expected in diabetes insipidus is polyuria.

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