the nurse has been assigned to train the unlicensed nursing assistant about prioritizing care which client should the nurse instruct the unlicensed nu
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 5

1. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

Correct answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

2. The nurse understands that which are characteristics of anthrax? Select all that apply.

Correct answer: A

Rationale: The correct characteristics of anthrax are that cutaneous lesions become a black eschar, and flu-like symptoms are typical of pulmonary anthrax. Choice B is incorrect as it only covers the cutaneous anthrax characteristic and does not include the flu-like symptoms of pulmonary anthrax. Choice C is incorrect as gastrointestinal anthrax does not cause 'blood anthrax,' and Choice D is incorrect as flu-like symptoms are not associated with gastrointestinal anthrax.

3. What is the mission of the Army Medical Department?

Correct answer: C

Rationale: The correct answer is C: 'Maintain the health of the Army and preserve its combat effectiveness.' This mission statement reflects the primary goal of the Army Medical Department, which is to ensure that military personnel remain healthy and fit for duty to preserve the Army's fighting strength. Choices A, B, and D are incorrect because they do not capture the core purpose of the Army Medical Department, which is focused on the health and readiness of the military forces, rather than performing annual physical examinations, responding to disasters, or providing education and training.

4. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.

5. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.

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