ATI RN
ATI Comprehensive Exit Exam 2023
1. A nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube. Which of the following findings should the nurse report to the provider?
- A. Gastric pH of 2.5.
- B. Bowel sounds every 4 hours.
- C. Diarrhea of 250 mL in 24 hours.
- D. Gastric residual of 150 mL.
Correct answer: D
Rationale: A gastric residual of 150 mL may indicate delayed gastric emptying and should be reported to the provider.
2. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse implement?
- A. Place the client in a negative pressure room
- B. Wear an N95 respirator mask when entering the room
- C. Wear a gown and gloves when providing care to the client
- D. Place a face mask on the client
Correct answer: C
Rationale: The correct precaution to implement when caring for a client with Clostridium difficile infection is to wear a gown and gloves when providing care. Clostridium difficile is primarily spread through contact with feces, so wearing personal protective equipment like gowns and gloves is crucial in preventing the spread of the infection. Placing the client in a negative pressure room (Choice A) is not necessary for Clostridium difficile. While wearing an N95 respirator mask (Choice B) is important for airborne precautions, it is not required for Clostridium difficile. Placing a face mask on the client (Choice D) is not a standard precaution for preventing the spread of Clostridium difficile.
3. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?
- A. A chest x-ray reveals increased density in all fields
- B. The client reports feeling less anxious
- C. Diminished breath sounds are auscultated bilaterally
- D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg
Correct answer: B
Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.
4. A client who is at 12 weeks of gestation and has hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory values should the nurse report to the provider?
- A. Sodium 140 mEq/L
- B. Potassium 3.8 mEq/L
- C. Blood glucose 90 mg/dL
- D. Urine ketones present
Correct answer: D
Rationale: The correct answer is D: Urine ketones present. The presence of urine ketones indicates dehydration and inadequate glucose control in clients with hyperemesis gravidarum. Reporting this finding to the provider is crucial for prompt intervention to prevent further complications. Choices A, B, and C are within normal ranges and do not directly correlate with the condition of hyperemesis gravidarum. Therefore, they are not the priority values to report in this scenario.
5. A nurse is caring for a client who has chronic kidney disease and is experiencing fluid volume overload. Which of the following findings should the nurse expect?
- A. Decreased blood pressure
- B. Increased urine output
- C. Decreased heart rate
- D. Increased heart rate
Correct answer: A
Rationale: In a client with chronic kidney disease experiencing fluid volume overload, the nurse should expect a decreased blood pressure. Fluid volume overload can lead to poor cardiac output, which in turn can cause a decrease in blood pressure. Choices B, C, and D are incorrect. Increased urine output is not expected in fluid volume overload; decreased heart rate is not typically associated with fluid volume overload; and an increased heart rate is more commonly seen in response to fluid overload to compensate for the decreased cardiac output.
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