the nurse enters a clients room and the client is demanding release from the hospital the nurse reviews the clients record and noted that the client a
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 1

1. The nurse enters a client’s room and the client is demanding release from the hospital. The nurse reviews the client’s record and noted that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?

Correct answer: D

Rationale: The correct intervention for the nurse to initiate first is to notify the client’s healthcare provider of the client’s stated intent to leave the hospital. This action is crucial as it ensures that the client’s care and safety are appropriately managed. Option A is not the best choice as involving the family to persuade the client may not address the client's underlying concerns. Option B is incorrect because having the client sign self-discharge papers without further assessment is not appropriate. Option C is also incorrect as the client's request for treatment does not prevent them from leaving if they are deemed competent to make that decision.

2. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. Which is the order of basic CPR?

Correct answer: A

Rationale: The correct order of basic CPR is to first ensure the scene is safe to approach, then assess responsiveness. Next, call for help and start CPR with chest compressions, followed by checking the airway and giving rescue breaths. Choice B is incorrect as giving rescue breaths is usually done after the initial chest compressions. Choice C is incorrect as looking, listening, and feeling for breathing comes after starting compressions. Choice D is incorrect as chest compressions are usually the first step in basic CPR.

3. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

Correct answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

4. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

Correct answer: A

Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.

5. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Choice A, chronic kidney disease with a serum creatinine of 1.6 mg/dL, though concerning, does not indicate an immediate need for follow-up. Choice C, heart failure with a BNP of 140 pg/mL, may require monitoring but not immediate follow-up. Choice D, a male client with anemia and normal hemoglobin and hematocrit levels, does not warrant immediate attention based on the provided information.

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