for which client situation would a consultation with a rapid response team rrt be most appropriate
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

2. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

Correct answer: A

Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.

3. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

Correct answer: A

Rationale: The correct answer is A: "All of the above." Evaluation of learning after a colonoscopy would be evident if the client mentions all the statements provided. Mild tenderness in the abdominal muscles, starting with a light diet and progressing to a regular diet, and experiencing gas or bloating temporarily are all expected after a colonoscopy. Therefore, all the statements are correct in demonstrating the client's understanding of the post-procedure instructions. Choices B, C, and D provide accurate information about the expected outcomes following a colonoscopy, making them incorrect answers individually but correct when combined as option A.

4. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?

Correct answer: C

Rationale: The correct question for the nurse to ask the mother before administering the MMR vaccine to a 15-month-old is about the child's allergy to antibiotics. This is crucial because the MMR vaccine contains neomycin, an antibiotic, and being allergic to antibiotics like neomycin is a contraindication for the MMR vaccine. Asking about sore throats, eating habits, or exposure to infections is not directly relevant to the administration of the MMR vaccine.

5. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of 'Educate personnel on UCMJ'?

Correct answer: B

Rationale: The correct answer is 'B: Personal/professional development.' Educating personnel on the Uniform Code of Military Justice (UCMJ) falls under the realm of personal/professional development, as it aims to enhance the knowledge and skills of individuals regarding military laws and regulations. Choice A, 'Accountability,' focuses more on responsibility and answerability rather than education. Choice C, 'Individual training,' is more specific to skill development and job-related learning rather than legal education. Choice D, 'Military appearance/physical condition,' pertains to maintaining physical standards and appearance, which is unrelated to educating personnel on UCMJ.

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