ATI RN
ATI Comprehensive Exit Exam 2023 With NGN
1. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?
- A. Frothy, pink sputum
- B. Jugular vein distention
- C. Weight gain
- D. Bradypnea
Correct answer: A
Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.
2. A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?
- A. PT 28 seconds
- B. INR 1.2
- C. aPTT 40 seconds
- D. Fibrinogen 350 mg/dL
Correct answer: B
Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.
3. A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification bracelet.
- B. Obtain the client's vital signs.
- C. Initiate the transfusion slowly over the first 15 minutes.
- D. Verify the client's blood type and Rh factor.
Correct answer: D
Rationale: The correct answer is to verify the client's blood type and Rh factor first before administering blood. This is crucial to ensure compatibility and prevent transfusion reactions. Checking the client's identification bracelet (Choice A) is important but should come after verifying blood type. Obtaining vital signs (Choice B) and initiating the transfusion slowly (Choice C) are important steps but verifying blood type is the priority to ensure safe blood administration.
4. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?
- A. Placing a belt restraint on a school-age child who has seizures.
- B. Securing wrist restraints to the bed rails for an adolescent.
- C. Applying elbow immobilizers to an infant receiving cleft lip injury.
- D. Keeping the side rails of a toddler's crib elevated.
Correct answer: D
Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.
5. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?
- A. Does the doctor know you are eating that?
- B. Why are you eating seaweed soup?
- C. Of course, I will heat that up for you.
- D. The hospital food is more nutritious.
Correct answer: C
Rationale: Respecting cultural preferences and providing client-centered care promotes trust.
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