ATI Exit Exam 180 Questions Quizlet

Correct Answer: C

Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

Correct Answer: A

Rationale: In osteoarthritis, joint pain that improves with rest is a common characteristic due to the relief obtained by reducing weight-bearing on the affected joint. Joint stiffness that improves with movement is more indicative of rheumatoid arthritis, not osteoarthritis. Red, warm joints are typically seen in inflammatory arthritis conditions like rheumatoid arthritis, while systemic inflammation is not a primary feature of osteoarthritis.

Correct Answer: D

Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.

Correct Answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

Correct Answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.