(ATI RN )Comp.Online Practice A (with NGN)
2024-2025
A nurse is caring for a client who has a fractured femur and has a fiberglass leg
cylinder cast for 24 hours. What is the priority assessment finding? -
......answer. ...... the client's heel is reddened and tender because this could be an
early indicator of a pressure injury and the pt is at high risk for pressure injuries
why are the other findings not priorities?
- cast gets wet: fiberglass casts are waterproof
- increase pain when leg is lowered below level of the heart: the leg should be
elevated to help reduce edema and pain but preventing pressure injuries is
priority
- the pt reports itching under the cast: the pt is at risk for dry and itchy skin so
the nurse should offer a hair dryer to blow COOL air on the skin, but preventing
pressure injury is priority
A nurse is providing client education to a postpartum client who has decided to
bottle feed the newborn. Which of the following instructions should the nurse
include in the teaching to help prevent the discomfort of engorgement? -
......answer. ...... place ice packs on the breasts for 15 min several times per day
because this helps reduce swelling and relieve pain
1|Page
,why are the other instructions incorrect?
- allow the newborn to breastfeed temporarily: avoid nipple stimulation because
this will increase milk production
- relieve pressure by expressing milk daily: avoid expressing milk to prevent
further milk production
- sleep with a loose fitting bra to prevent nipple stimulation: wear a tight fighting,
supportive bra or a breast binder to decrease discomfort caused by engorgement
A nurse is preparing to insert an indwelling urinary catheter for a client. The
nurse should assess the client for which of the following conditions prior to
starting the procedure? - ......answer. ............. latex allergy because of the risk of an
allergic reaction to the catheter
why are the other answers incorrect?
- ketonuria: this is the presence of ketones in the urine and occurs
- fecal impaction or tachycardia: these conditions do not pose a safety risk during
the insertion of an indwelling catheter
ketonuria - ......answer. ........ this is the presence of ketones in the urine and occurs
due to fatty acid catabolism caused by hyperglycemia, starvation, high-protein
diets, and alcohol use disorder
2|Page
,sickle cell anemia - ......answer. .......... a genetic disorder that causes abnormal
hemoglobin, resulting in some red blood cells assuming an abnormal sickle
shape
vaso-occlusive crisis - ......answer. ............ Ischemia and pain caused by sickle-shaped
red blood cells that obstruct blood flow to a portion of the body,
for example an organ becomes restricted, causing pain, ischemia and often organ
damage
other s/s: visual disturbance, hematuria, painful swelling extremities, fever,
tachycardia, PAIN
A nurse is assessing a client who has sickle cell anemia. The nurse should
identify which of the following findings as a manifestation of vase-occlusive
crisis? - ......answer ......... hematuria because it is a manifestation that results from
ischemia of the kidneys
what answers are not signs of vast-occlusive crisis?
- diminished reflexes, hyperglycemia, hearing loss
what are other signs of vast-occlusive crisis? painful swelling of the hands and
feet, visual disturbances
3|Page
, A nurse is assessing a client during the immediate postpartum period. Which of
the following findings requires immediate intervention by the nurse? -
......answer. ...... boggy uterus because this can indicate uterine hemorrhage and
this is URGENT
why do the other findings not require immediate intervention by the nurse?
- intermittent cramping, moderate lochia rubra, and perineal edema are all
NONURGENT and are expected findings
- excessive lochia rubra and large clots should be reported to the provider
- intermittent cramping/afterpainscan be eased by heat and lying prone
- perineal edema occurs due to the excessive amount of pressure experienced
during vaginal birth, the nurse can offer ice or sitz baths
what does the nurse do if the pt has a "boggy uterus" during the immediate
postpartum period? - ......answer. ........... this is URGENT and can indicate a uterine
hemorrhage, so the nurse should IMMEDIATELY intervene to stimulate uterine
contractions and prevent blood loss, because if the uterus becomes relaxed
during the postpartum period the client will rapidly lose blood because no
permanent thrombi have formed at the placenta
4|Page
2024-2025
A nurse is caring for a client who has a fractured femur and has a fiberglass leg
cylinder cast for 24 hours. What is the priority assessment finding? -
......answer. ...... the client's heel is reddened and tender because this could be an
early indicator of a pressure injury and the pt is at high risk for pressure injuries
why are the other findings not priorities?
- cast gets wet: fiberglass casts are waterproof
- increase pain when leg is lowered below level of the heart: the leg should be
elevated to help reduce edema and pain but preventing pressure injuries is
priority
- the pt reports itching under the cast: the pt is at risk for dry and itchy skin so
the nurse should offer a hair dryer to blow COOL air on the skin, but preventing
pressure injury is priority
A nurse is providing client education to a postpartum client who has decided to
bottle feed the newborn. Which of the following instructions should the nurse
include in the teaching to help prevent the discomfort of engorgement? -
......answer. ...... place ice packs on the breasts for 15 min several times per day
because this helps reduce swelling and relieve pain
1|Page
,why are the other instructions incorrect?
- allow the newborn to breastfeed temporarily: avoid nipple stimulation because
this will increase milk production
- relieve pressure by expressing milk daily: avoid expressing milk to prevent
further milk production
- sleep with a loose fitting bra to prevent nipple stimulation: wear a tight fighting,
supportive bra or a breast binder to decrease discomfort caused by engorgement
A nurse is preparing to insert an indwelling urinary catheter for a client. The
nurse should assess the client for which of the following conditions prior to
starting the procedure? - ......answer. ............. latex allergy because of the risk of an
allergic reaction to the catheter
why are the other answers incorrect?
- ketonuria: this is the presence of ketones in the urine and occurs
- fecal impaction or tachycardia: these conditions do not pose a safety risk during
the insertion of an indwelling catheter
ketonuria - ......answer. ........ this is the presence of ketones in the urine and occurs
due to fatty acid catabolism caused by hyperglycemia, starvation, high-protein
diets, and alcohol use disorder
2|Page
,sickle cell anemia - ......answer. .......... a genetic disorder that causes abnormal
hemoglobin, resulting in some red blood cells assuming an abnormal sickle
shape
vaso-occlusive crisis - ......answer. ............ Ischemia and pain caused by sickle-shaped
red blood cells that obstruct blood flow to a portion of the body,
for example an organ becomes restricted, causing pain, ischemia and often organ
damage
other s/s: visual disturbance, hematuria, painful swelling extremities, fever,
tachycardia, PAIN
A nurse is assessing a client who has sickle cell anemia. The nurse should
identify which of the following findings as a manifestation of vase-occlusive
crisis? - ......answer ......... hematuria because it is a manifestation that results from
ischemia of the kidneys
what answers are not signs of vast-occlusive crisis?
- diminished reflexes, hyperglycemia, hearing loss
what are other signs of vast-occlusive crisis? painful swelling of the hands and
feet, visual disturbances
3|Page
, A nurse is assessing a client during the immediate postpartum period. Which of
the following findings requires immediate intervention by the nurse? -
......answer. ...... boggy uterus because this can indicate uterine hemorrhage and
this is URGENT
why do the other findings not require immediate intervention by the nurse?
- intermittent cramping, moderate lochia rubra, and perineal edema are all
NONURGENT and are expected findings
- excessive lochia rubra and large clots should be reported to the provider
- intermittent cramping/afterpainscan be eased by heat and lying prone
- perineal edema occurs due to the excessive amount of pressure experienced
during vaginal birth, the nurse can offer ice or sitz baths
what does the nurse do if the pt has a "boggy uterus" during the immediate
postpartum period? - ......answer. ........... this is URGENT and can indicate a uterine
hemorrhage, so the nurse should IMMEDIATELY intervene to stimulate uterine
contractions and prevent blood loss, because if the uterus becomes relaxed
during the postpartum period the client will rapidly lose blood because no
permanent thrombi have formed at the placenta
4|Page
