ATI RN
ATI Comprehensive Exit Exam 2023
1. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?
- A. Inject the medication into the deltoid muscle
- B. Inject the medication deep into subcutaneous tissue
- C. Massage the injection site for 2 minutes after administration
- D. Insert the needle at a 10-degree angle
Correct answer: B
Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.
2. A nurse is assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?
- A. Heart rate 68/min.
- B. Blood pressure 110/70 mm Hg.
- C. Vision changes.
- D. Respiratory rate 18/min.
Correct answer: C
Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.
3. A group of newly licensed nurses is being taught about client advocacy by a nurse. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
- A. I will intervene if there is a conflict between a client and their provider.
- B. I should not advocate for a client unless they are able to ask me themselves.
- C. I will inform a client that their family should help make their health care decisions.
- D. I believe the best health care decision is for the provider to decide.
Correct answer: B
Rationale: The correct answer is B because advocating for a client should not be dependent on the client's ability to ask for it personally. Advocacy is crucial to ensure clients' rights are upheld, especially when they are unable to express their wishes. Choice A is incorrect as intervening in a conflict may not always be advocating for the client's best interests. Choice C is incorrect because the family should not make health care decisions for the client without their input. Choice D is incorrect as it disregards the importance of client autonomy and involvement in decision-making.
4. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Apply a sterile dressing.
- B. Suction the tracheostomy.
- C. Remove the inner cannula.
- D. Clean the stoma with sterile saline.
Correct answer: B
Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.
5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid aspirin while taking this medication.
- B. I will increase my intake of green leafy vegetables.
- C. I will take this medication with an antacid.
- D. I should expect mild bruising around my elbows.
Correct answer: A
Rationale: The correct answer is A: "I will avoid aspirin while taking this medication." Clients taking warfarin should avoid aspirin due to the increased risk of bleeding. Choice B is incorrect because increasing the intake of green leafy vegetables high in Vitamin K can interfere with the effects of warfarin. Choice C is incorrect because warfarin should not be taken with antacids as they can decrease its absorption. Choice D is incorrect because mild bruising is a common side effect of warfarin due to its anticoagulant properties.
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