ATI RN
ATI RN Custom Exams Set 5
1. The nurse is aware that norepinephrine is secreted by which endocrine gland?
- A. The pancreas
- B. The adrenal cortex
- C. The adrenal medulla
- D. The anterior pituitary gland
Correct answer: C
Rationale: The correct answer is C: The adrenal medulla. Norepinephrine is secreted by the adrenal medulla and is involved in the body's 'fight or flight' response. The pancreas (choice A) secretes insulin and glucagon, not norepinephrine. The adrenal cortex (choice B) secretes hormones like cortisol and aldosterone, but not norepinephrine. The anterior pituitary gland (choice D) secretes various hormones like growth hormone and thyroid-stimulating hormone, but not norepinephrine.
2. Which discharge instruction should the nurse provide to the client diagnosed with varicose veins who has received sclerotherapy?
- A. Walk 15 to 20 minutes three (3) times a day.
- B. Keep the legs in the dependent position when sitting.
- C. Remove compression bandages before going to bed.
- D. Perform Berger-Allen exercises (4) times a day.
Correct answer: A
Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B, keeping the legs in the dependent position when sitting, is incorrect as it can increase venous pressure. Choice C, removing compression bandages before going to bed, is incorrect as compression should be maintained as per healthcare provider's instructions. Choice D, performing Berger-Allen exercises four times a day, is incorrect as these exercises may not be specifically recommended post-sclerotherapy.
3. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?
- A. The assistant is putting the stockings on while the client is in the chair.
- B. The assistant inserted two (2) fingers under the proximal end of the stocking.
- C. The assistant elevated the feet while lying down to put on the stockings.
- D. The assistant made sure the toes were warm after putting the stockings on.
Correct answer: A
Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.
4. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?
- A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes
- B. The nurse noted unilateral breast enlargement
- C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass
- D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.
Correct answer: D
Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.
5. During synchronized cardioversion on a client in atrial fibrillation, when the machine is activated, and there is a pause, what action should the nurse take?
- A. Wait until the machine discharges
- B. Shout “all clear” and don’t touch the bed
- C. Make sure the client is all right
- D. Increase the joules and re-discharge
Correct answer: B
Rationale: The correct action for the nurse to take when there is a pause after the machine is activated during synchronized cardioversion is to shout “all clear” and ensure that no one is touching the client or the bed to prevent them from being shocked. This step is crucial for the safety of everyone present during the procedure. Choices A, C, and D are incorrect because waiting without confirming safety, focusing on the client's condition only, or increasing joules without safety precautions can lead to potential harm or injury.
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