NGN ATI COMPREHENSIVE EXIT R E T A K E EXAM testbank-LATEST RELIABLE STUDY GUIDE; QUESTIONS,ANSWERS AND RATIONALES-graded A+ 2024

NGN ATI COMPREHENSIVE EXIT R E T A K E
EXAM testbank-LATEST RELIABLE STUDY GUIDE;
QUESTIONS,ANSWERS AND RATIONALES-graded A+
2024
1. A nurse is caring for a client who is at 33 weeks gestation following an
amniocentesis. The nurse should monitor the client for which of the following
complications?
a. contractions
b. Hypertention
c. Epigastric pain
d. vomiting
Answer: a. Contraction
Rational: Amniocentesis
-Can't be done before 16 weeks, not enough amniotic fluid.
-maternal risks: hemorrhage, feto maternal hemorrhage, infection, contractions/labor,
abruptio placentae, damage to intestines or bladder, amniotic fluid embolism
-fetal risks: death, hemorrhage, infection, direct injury from the needle, miscarriage, and
preterm, leakage of amniotic fluid
2. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Stay in bed at least 1 hr if unable to fall asleep.
b. Take a 1 hr nap during the day
c. Perform exercises prior to bedtime
d. Eat a light snack before bedtime
Answer:D. Eat a light snack before bedtime
Rational:Consume a light snack of carbohydrates at bedtime
3. A nurse on a telemetry unit is caring for a client who becomes unconscious and
whose monitor displays ventricular tachycardia. Which of the following actions should
the nurse first take determining the client does not have a palpable pulse?
a. Assess heart sounds
b. Defibrillate
c. Establish IV access
d. Administer Epinephrine
Answer:B. Defibrillate
Rational: The nurse needs to assess the client to determine stability before
proceeding with further interventions. If the client has a pulse and is relatively
stable, elective cardioversion or antidysrhythmic medications may be
prescribed. The drug of choice for stable ventricular
tachycardia with a pulse is amiodarone. If the client is pulseless or
nonresponsive, the client is unstable and defibrillation is used
4. A nurse is admitting a client who is one week postpartum and reports excessive
vaginal bleeding. The nurse does not speak the same language as the client the client’s
partner and 10-year-old child are accompanying her. Which of the following actions
should the nurse take to gather the client’s admission data?
a. Have the client’s child translate
b. Allow the client’s partner to translate
c. Request a female interpreter through the facility
d. Ask a nursing student who speaks the same language as the client to translate.
Answer: C. Request a female interpreter through the facility
Rational: We been told not to use family members if not facility interpreters
5. A nurse is caring for a client who is febrile(fever). To reduce the client’s fever, the
nurse applies cooling. Which of the following indicates the client is having an adverse
reaction to the cooling?
a. Flushing
b. Tachycardia
c. Restlessness
d. Shivering
Answer: D. shivering
Rational: Hypothermia is the adverse reaction of cooling system for a febrile
patient s/s of hypothermia: shivering, slurred speech, weak pulse
drowsiness, confusion, loss of memory
6. A nurse is caring for a client who has deep-vein thrombosis of the left lower
extremity. Which of the following actions should the nurse take?
The Answer should be: ensure that the lower extremity is elevated.
Rational: DVT causes edema; therefore, the UAP should elevate the extremity to
promote venous return. Dependent positioning is appropriate for a client with
arterial insufficiency. Placing a pillow under the knee would position the foot in
a low position, and pressure behind the knee may obstruct venous flow.
Massaging the extremity could dislodge the thrombus
7. A nurse is reviewing assessment data from several clients. For which of the
following clients should the nurse recommend referral to a dietitian?
a. An older adult client who has BMI of 24
b. A client who has a nonhealing leg ulcer
c. An older adult client who had presbyopia
d. A client who has an albumin level of 3.7 g/dl
Answer:B. A client who has a nonhealing leg ulcer
Rational: type of patients that can be referred to dietitian are the ones that
present: Physical S&S Malnutrition
Hair is dull, brittle, dry, or falls out easily
Swollen glands of neck and cheeks
Dry, rough, or spotty skin
Poor or delayed wound healing or sores
Thin appearance with lack of subcutaneous fat
Muscle wasting
Edema of lower extremities
Weakened hand grasp
Depressed mood
Abnormal heart rate/rhythm and BP
Enlarged liver or spleen
Loss of balance and coordination
Presbyopia: farsighted
8. A nurse is providing discharge teaching to a client who has chronic kidney disease
and is receiving hemodialysis. Which of the following instructions should the nurse
include in the teaching?
a. Eat 1g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily.
d. Consume foods high in K+
Answer: A. Eat 1g/kg of protein per day
Rational: Protein intake and hemodialysis
protein is not routinely restricted.
Magnesium hydroxide. Please don’t chose this anwer!
-Magnesium is excreted by the kidneys, and patients with CKD should not use
OTC products containing magnesium. The other mediations are appropriate for
a patient with CKD.
9. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
a. Sitting in high-fowlers position during the feeding
b. History of gastroesophageal reflux disease (GERD)
c. Receiving a high osmolality formula
d. A residual of 65ml 1 hr postprandial
Answer: B. History of gastroesophageal reflux disease (GERD)
Rational: Pt with higher Risk of aspiration a in clients with GERD