ATI RN
ATI Comprehensive Exit Exam
1. A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?
- A. aPTT 75 seconds.
- B. INR 1.2.
- C. Hemoglobin 10 g/dL.
- D. Fibrinogen level 350 mg/dL.
Correct answer: A
Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.
2. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?
- A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
- B. Heart rate of 68/min.
- C. Potassium level of 3.8 mEq/L.
- D. Urine output of 60 mL/hr.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.
3. A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?
- A. Massage the injection site after administering the medication.
- B. Insert the needle at a 45° angle.
- C. Use a Z-track technique to administer the injection.
- D. Aspirate for blood before injecting the medication.
Correct answer: C
Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.
4. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis.
- B. Administer flumazenil to the client.
- C. Evaluate the client for further suicidal behavior.
- D. Initiate seizure precautions for the client.
Correct answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.
5. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. You should lie down before taking this medication.
- B. You should take this medication on an empty stomach.
- C. You should never take a double dose if you miss one.
- D. You should store this medication in its original container at room temperature.
Correct answer: A
Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to lie down before taking the medication. Nitroglycerin can cause a sudden drop in blood pressure leading to dizziness or fainting, so taking the medication while lying down helps prevent falls. Choice B is incorrect because nitroglycerin is usually taken on an empty stomach to enhance its absorption. Choice C is incorrect as taking a double dose of nitroglycerin can lead to low blood pressure and other adverse effects. Choice D is incorrect as nitroglycerin sublingual tablets should be stored in their original container at room temperature away from light and moisture, not in the refrigerator.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99