ATI RN Comprehensive Online Practice A with NGN 2024-2025 ACTUAL REAL PRACTICE EXAM UPDATED QUESTION AND DETAILED ANSWER WITH RATIONALES ANSWERS.

ATI RN Comprehensive
Online Practice A with
NGN 2024-2025
ACTUAL REAL
PRACTICE EXAM
UPDATED QUESTION
AND DETAILED
ANSWER WITH
RATIONALES
ANSWERS.
A nurse is providing colostomy care for a client
using a two-piece pouching system. Which of the
following actions should the nurse take? - ANSWERplace the skin barrier over the stoma and hold for
30 seconds to activate the adhesive in the skin.
barrier
Rationale.
why are the other answers incorrect?
- cleanse the stoma site with povidone-iodine for 15
seconds: the skin at the stoma site should be
cleansed with a washcloth and warm water to
reduce risk of skin irritation
- dampen the skin before apply the skin barrier and
the ostomy pouch: the nurse should thoroughly dry
the skin around the stoma using a patting motion
before applying the skin barrier to ensure the pouch
adheres to the clients skin
- cut the skin barrier opening 0.6 cm larger than the
stoma: do not cut the skin barrier opening more
than 0.3 cm larger than the stoma to reduce the risk
of skin irritation
A nurse is assessing a client who has sickle cell
anemia. The nurse should identify which of the
following findings as a manifestation of vaseocclusive crisis? - ANSWER-hematuria because it is a
manifestation that results from ischemia of the
kidneys
Rationale.
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
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
Rationale.
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
Rationale.
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
sickle cell anemia - ANSWER-a genetic disorder that
causes abnormal hemoglobin, resulting in some red
blood cells assuming an abnormal sickle shape
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
Rationale.
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