ATI COMPREHENSIVE exit exam A

ATI COMPREHENSIVE exit exam A 1. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? a. You only need to receive Rh immune globulin if you have a positive blood type." b. You should receive Rh immune globulinwithin 72 hours of delivery." c. "Both you and your baby should receive Rh immune globulin at your -week appointment." d. "immune globulin is not necessary since this is your second pregnancy." 2. A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. Ican use my ultrasound picture as a focal point during contractions 3. Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications shouldthe nurse expect to be the highest priority to administer to the client? a. Promethazine b) Hydromorphone c) Ketorolac d) Amitriptyline 4. A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care? a. Live with the clients fluid intake to 1500 mL per day b. Massage place affected extremity to relieve pain c. Apply cold packs of clients affected extremity d. Elevate the client’s affected extremity when in bed 5. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take? a. Discontinue oxytocin infusion b. Increased oxytocin infusion c. Decreased oxytocin infusion d. Maintain oxytocin infusion 6. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client? a) Have your membranes ruptured? 2 of 28 b) How far apart are your contractions? c) Do you have any active lesions? d) Are you positive for beta strap? 7. Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should the nurse include? a. Take with meals b. Take at bedtime c. Take with a glass of milk d. Take with a glass of orange juice 8. Four clients present to the emergency department. The nurse should plan to see which of the following clients first? a. A 6 year old client whose left shoulder is dislocated b. A 26 year old client for sickle cell disease and a severe joint pain c. A 76 year old client was confused, febrile and has foul smelling urine - uti d. A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke 9. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility a. Ask a student nurse who speaks the same language to translate b. Have the child translate c. Allow the clients partner to translate 10. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? a. Folate level b. INR level c. Vitamin b12 level d. Creatinine level 11. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device 12. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus) c. Uterine atony( fundus not firm which means possible hemorrhage) d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly) 13. A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ? a. Polyuria- oliguria b. Hypotension- hypertension c. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine d. Weight loss - weight gain