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This Exam contains: ATI RN COMPREHENSIVE
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,Question 1
A nurse is caring for a group of clients. Which of the following wounds should the nurse expect
to heal by primary intention?
a. Approximated surgical incision
b. Infected laceration
c. Stage II pressure ulcer
d. Partial-thickness burn
Correct Answer
CORRECT: a. Approximated surgical incision
PRIMARY FASTEST TYPE ON ITS OWN, SECONDARY
REQUIRES GRANULATION TISSUES AND CREATES SCAR TISSUES, AND TETRIARY
IS DELAYED WOUND CLOSURE.
INCORRECT RATIONALE:
b. Infected laceration- TERTIARY
c. Stage II pressure ulcer -SECONDARY
d. Partial-thickness burn- SECONDARY
Question 2
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
a. Vomiting
b. Hypertension
c. Epigastric pain
d. Contractions
Correct Answer
d. contractions
Question 3
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
Correct Answer
d. Eat a light snack before bedtime
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,Question 4
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
take first after determining the client does not have a palpable pulse?
a. Assess heart sounds
b. Defibrillate
c. Establish IV access
d. Administer epinephrine
Correct Answer
b. Defibrillate
Question 5
A nurse is admitting a client who 1 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
Correct Answer
c. Request a female interpreter through the facility
Question 6
A nurse is caring for a client who is febrile (High fever). To reduce the client's fever, the nurse
applies a cooling blanket. Which of the following findings indicates the client is having an
adverse reaction to the cooling?
a. Flushing
b. Tachycardia
c. Restlessness
d. Shivering (Hypothermic)
Correct Answer
d. Shivering (Hypothermic)
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, Question 7
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? (Exhibit)
lab findings:
aPTT 100 secs
Platelets 140,000/mm3
INR 2.0
MAR:
heparin IV infusion 1000 u/hr
warfarin 2 mg PO daily
acetaminophen 650 mg PO every 4 hr PRN temperature greater than 38.6 C (101.5 F)
hydrocodone bitartrate 5 mg/acetaminophen 500 mg PO PRN pain greater than 5 on a scale from 0 to 10
a. Position the client with the affected extremity lower than the heart
b. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
c. Administer acetaminophen
d. Massage the affected extremity every 4 hr
Correct Answer
b. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
Question 8
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 a BMI of 24 (18.5-24.9)
b. A client who has a nonhealing leg ulcer (diet isn't good)
c. An older adult client who has presbyopia (age related far-sightness)
d. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
Correct Answer
b. A client who has a nonhealing leg ulcer (diet isn't good)
Question 9
A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
a. Eat 1 g/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 potassium- restrict
Correct Answer
a. Eat 1 g/kg of protein per day
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