ATI RN
ATI Comprehensive Exit Exam
1. A client in active labor has ruptured membranes. What action should the nurse take?
- A. Apply a fetal heart rate monitor.
- B. Initiate fundal massage.
- C. Administer oxytocin IV.
- D. Insert an indwelling urinary catheter.
Correct answer: A
Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.
2. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
- A. Position the client supine.
- B. Prepare an IV bolus of dextrose 5% in water.
- C. Administer methylergonovine IM.
- D. Administer calcium gluconate IV.
Correct answer: D
Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.
3. A client with chronic kidney disease is receiving dietary teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of bananas.
- B. I will limit my intake of foods high in potassium.
- C. I will increase my intake of protein-rich foods.
- D. I will increase my intake of dairy products.
Correct answer: B
Rationale: The correct answer is B. Limiting potassium-rich foods is crucial for clients with chronic kidney disease to prevent hyperkalemia, a common complication. Increasing intake of potassium-rich foods like bananas (choice A), protein-rich foods (choice C), or dairy products (choice D) can exacerbate hyperkalemia in these clients. Bananas, protein-rich foods, and dairy products are all high in potassium, which is detrimental for individuals with chronic kidney disease. Therefore, choices A, C, and D are incorrect.
4. A client who has a new prescription for prednisone is being discharged. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I will need to take this medication for the rest of my life.
- C. I should avoid crowded places while taking this medication.
- D. I will take this medication until my symptoms resolve.
Correct answer: C
Rationale: The correct answer is C. Clients taking prednisone should avoid crowded places to reduce the risk of infection due to immunosuppression. Choice A is incorrect because prednisone should be taken with food to reduce stomach upset. Choice B is incorrect as prednisone is usually prescribed for a specific duration and not for life. Choice D is incorrect because prednisone should be taken as prescribed by the healthcare provider, which may not always align with symptom resolution.
5. A client has a chest tube connected to a water-seal drainage system. Which of the following actions should be taken?
- A. Clamp the chest tube during ambulation
- B. Keep the collection chamber below the level of the chest
- C. Add sterile water to the water-seal chamber
- D. Empty the collection chamber every 12 hours
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with a chest tube connected to a water-seal drainage system is to add sterile water to the water-seal chamber. This is necessary to maintain the correct water level for proper chest tube function. Clamping the chest tube during ambulation (Choice A) is incorrect as it can lead to complications by obstructing drainage. Keeping the collection chamber below the level of the chest (Choice B) is incorrect because it should be kept below the chest to facilitate drainage. Emptying the collection chamber every 12 hours (Choice D) is incorrect as it should be emptied whenever it reaches the fill line or as per facility policy, not on a fixed time schedule.
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