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 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.
3. 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.
4. A nurse is providing discharge teaching to a client with type 2 diabetes mellitus. Which of the following resources should the nurse provide?
- A. Personal blogs about managing diabetes medications.
- B. Food label recommendations from the Institute of Medicine.
- C. Diabetes medication information from the Physicians' Desk Reference.
- D. Food exchange lists for meal planning from the American Diabetes Association.
Correct answer: D
Rationale: The correct answer is D. Food exchange lists are valuable resources for individuals with diabetes as they provide structured meal planning guidance. This helps individuals manage their diabetes effectively by controlling their carbohydrate intake. Choices A, B, and C are incorrect because personal blogs may not provide reliable and evidence-based information, food label recommendations from the Institute of Medicine may not be specific for diabetes meal planning, and diabetes medication information from the Physicians' Desk Reference is not directly related to meal planning for diabetes management.
5. A nurse is assessing a school-age child with a urinary tract infection. Which symptom should the nurse expect?
- A. Periorbital edema.
- B. Decreased frequency of urination.
- C. Enuresis.
- D. Diarrhea.
Correct answer: C
Rationale: Enuresis is a common symptom of urinary tract infections in school-age children. It is often a presenting symptom due to irritation of the bladder. Periorbital edema (Choice A) is more indicative of conditions like nephrotic syndrome or renal disorders. Decreased frequency of urination (Choice B) is not typically associated with urinary tract infections. Diarrhea (Choice D) is not a common symptom of urinary tract infections but may occur due to other reasons like gastrointestinal infections.
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