ATI RN
ATI Comprehensive Exit Exam
1. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serous drainage at the incision site
- B. Temperature 38.2°C (100.8°F)
- C. Heart rate 92/min
- D. Blood pressure 130/80 mm Hg
Correct answer: B
Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.
2. A healthcare professional is reviewing the medical record of a client scheduled for a CT scan with contrast media. The healthcare professional should identify which of the following findings as a contraindication to the procedure?
- A. White blood cell count of 6,000/mm³
- B. Urine specific gravity of 1.025
- C. History of asthma
- D. History of allergy to shellfish
Correct answer: D
Rationale: The correct answer is D, a history of allergy to shellfish. A known allergy to shellfish is a contraindication for the use of contrast media in a CT scan due to the potential risk of an allergic reaction, which could be severe and life-threatening. Choices A, B, and C are not contraindications to the procedure. A normal white blood cell count, urine specific gravity within the normal range, and a history of asthma do not typically interfere with the administration of contrast media for a CT scan.
3. A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication 1 hour before meals.
- B. I should take this medication 30 minutes after meals.
- C. I should take this medication only when I have symptoms of heartburn.
- D. I should take this medication with a glass of milk.
Correct answer: A
Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.
4. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?
- A. A client receives antibiotics 2 hours late.
- B. A client vomits within 20 minutes of taking morning medications.
- C. A client requests a statin to be administered at 2100.
- D. A client asks for pain medication 1 hour early.
Correct answer: A
Rationale: The correct answer is A. Administering antibiotics late must be reported as it can compromise the effectiveness of the treatment. This delay can lead to subtherapeutic levels of the antibiotic in the client's system, potentially reducing its efficacy in combating the infection. Choice B, a client vomiting shortly after taking medication, should be noted but does not necessarily require an incident report unless it is a frequent occurrence. It could indicate a possible adverse reaction or intolerance to the medication. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication slightly earlier, do not involve medication errors or deviations that pose immediate risks to the client's health, so they do not require incident reports.
5. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
- A. Position the client on their left side.
- B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
- C. Hold the container of the enema solution 61 cm (24 in) above the client.
- D. Advance the enema tubing 15 cm (6 in) into the client's rectum.
Correct answer: C
Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.
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