ATI RN
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Question 1 of 5
What should the nurse monitor first for a client with a recent stroke?
Correct Answer: C
Rationale: The correct answer is C: Administer aspirin. Aspirin should be administered first to prevent further clot formation and reduce the risk of recurrent stroke. Monitoring blood pressure (A) is important but not the first priority. Administering IV fluids (B) is not necessary unless indicated. Applying a warm compress (D) is not a priority in the acute management of a stroke. Administering aspirin promptly can significantly impact the client's outcome by preventing further clot formation.
Question 2 of 5
A nurse is caring for a patient who is receiving chemotherapy. The nurse should prioritize monitoring for which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Neutropenia. Neutropenia is a common side effect of chemotherapy where there is a decrease in neutrophil count, increasing the risk of infections. Monitoring for neutropenia is crucial to prevent serious infections and sepsis in chemotherapy patients. Hyperkalemia (B), chronic pain (C), and hypertension (D) are not direct complications of chemotherapy and do not pose immediate life-threatening risks to patients undergoing chemotherapy. Monitoring for neutropenia takes precedence due to the potential for life-threatening infections in immunocompromised patients.
Question 3 of 5
Which physical finding indicates developmental dysplasia of the hip in an 11-12-month-old child?
Correct Answer: B
Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.
Question 4 of 5
What does the nurse use as a framework when planning individualized care for a community?
Correct Answer: A
Rationale: The correct answer is A: Nursing process. The nursing process consists of systematic steps (assessment, diagnosis, planning, implementation, evaluation) used by nurses to provide individualized care. Assessment helps identify community needs, diagnosis guides problem identification, planning involves setting goals, implementation is about carrying out interventions, and evaluation assesses outcomes. Diagnostic reasoning (B) refers to the process of analyzing data to make clinical decisions, not for planning community care. Critical thinking (C) is a general cognitive process that aids decision-making but is not specific to planning community care. Community care map (D) may be a tool used within the nursing process but is not the overarching framework for planning individualized care.
Question 5 of 5
Which action should not be performed when fetal distress is indicated?
Correct Answer: C
Rationale: The correct answer is C: decrease maternal fluids. When fetal distress is indicated, decreasing maternal fluids helps prevent further stress on the fetus by reducing the volume of amniotic fluid. This can help improve blood flow to the placenta and oxygen delivery to the baby. Increasing maternal fluids (choice A) can worsen the situation by potentially increasing amniotic fluid volume and further compromising fetal oxygenation. Administering oxygen (choice B) is important to improve oxygen supply to the fetus. Turning the mother (choice D) can help relieve pressure on the baby but is not the primary action when fetal distress is indicated.
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