ATI RN
ATI Comprehensive Exit Exam 2023
1. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?
- A. Clamp the catheter.
- B. Administer a fluid bolus.
- C. Obtain a urine specimen for culture and sensitivity.
- D. Initiate continuous bladder irrigation.
Correct answer: D
Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.
2. A client post-thyroidectomy reports tingling in their lips and fingers. The nurse should identify this finding as an indication of which of the following complications?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hyponatremia
- D. Hyperglycemia
Correct answer: B
Rationale: Tingling in the lips and fingers is a classic sign of hypocalcemia, which can occur as a complication following a thyroidectomy due to inadvertent damage to the parathyroid glands that regulate calcium levels. Hypokalemia (Choice A) presents with muscle weakness and cardiac issues, not tingling. Hyponatremia (Choice C) typically manifests with confusion, seizures, and muscle cramps. Hyperglycemia (Choice D) is associated with increased thirst, frequent urination, and fatigue.
3. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
- A. Stay in bed for at least 1 hour if unable to fall asleep.
- B. Take a 1-hour nap during the day.
- C. Perform exercise before bed.
- D. Eat a light snack before bedtime.
Correct answer: D
Rationale: The correct answer is to eat a light snack before bedtime. Consuming a light snack can help promote sleep by preventing discomfort from hunger. Choice A is incorrect because staying in bed for too long when unable to fall asleep can lead to frustration and worsen insomnia. Choice B is incorrect as taking a nap during the day can interfere with nighttime sleep. Choice C is incorrect as exercising before bed can increase alertness and make falling asleep more difficult.
4. A client who is 2 hours postoperative following a kidney biopsy is being assessed by a nurse. Which of the following findings should the nurse report to the provider?
- A. Urinary output of 30 mL/hr.
- B. Hemoglobin 10 g/dL.
- C. Respiratory rate of 16/min.
- D. Blood pressure 110/70 mm Hg.
Correct answer: B
Rationale: The correct answer is B. A hemoglobin level of 10 g/dL is below the normal range and should be reported following a kidney biopsy to check for bleeding. Decreased hemoglobin levels could indicate internal bleeding, which is a significant concern postoperatively. Choices A, C, and D are within normal limits and do not require immediate reporting. Urinary output of 30 mL/hr is also within the acceptable range for a postoperative client. A respiratory rate of 16/min and blood pressure of 110/70 mm Hg are both normal findings postoperatively.
5. 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 his antibiotics 2 hours late.
- B. A client vomits within 20 minutes of taking his morning medications.
- C. A client requests his 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. When a client receives antibiotics 2 hours late, it constitutes a medication error, requiring the completion of an incident report. Choice B, a client vomiting within 20 minutes of taking medications, does not necessarily require an incident report unless it is suspected to be related to a medication error. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication an hour early, are not incidents that mandate the completion of an incident report unless there are specific circumstances indicating otherwise.
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