the unlicensed nursing assistant is applying elastic compression stockings to the client which action by the assistant warrants immediate intervention
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 5

1. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A. 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 incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

2. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.

3. A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe a continuous infusion of insulin of:

Correct answer: B

Rationale: The correct answer is Novolin R (Regular insulin) because it is used for continuous infusion to treat diabetic ketoacidosis. Novolin R has a rapid onset of action, making it suitable for this acute situation. Novolin L insulin (Choice A) is not typically used for continuous infusion in diabetic ketoacidosis. Novolin N insulin (Choice C) is an intermediate-acting insulin and is not ideal for rapid correction needed in diabetic ketoacidosis. Novolin U insulin (Choice D) is an ultra-long-acting insulin and is not appropriate for the immediate correction required in this scenario.

4. What causes hepatic encephalopathy?

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.

5. The nurse is caring for the client one day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

Correct answer: D

Rationale: Assisting the client to sit in a chair is an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.

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