ATI RN
ATI Comprehensive Exit Exam 2023 With NGN Quizlet
1. A nurse is reviewing the medical record of a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Heart rate 90/min
- B. Serosanguineous drainage in the surgical drain
- C. Temperature 38.6°C (101.5°F)
- D. Urinary output 60 mL/hr
Correct answer: C
Rationale: The correct answer is C. A temperature of 38.6°C (101.5°F) is above the normal range and indicates a fever, which is a concerning finding postoperatively. Fever can be a sign of infection, so the nurse should report this finding to the provider for further evaluation and intervention. Choices A, B, and D are within expected parameters for a client who is 24 hours postoperative following abdominal surgery and do not require immediate reporting. A heart rate of 90/min, serosanguineous drainage in the surgical drain, and a urinary output of 60 mL/hr are all common postoperative findings that do not raise immediate concerns.
2. A nurse is reviewing the medical record of a client who has major depressive disorder and is taking tranylcypromine. Which of the following foods should the nurse instruct the client to avoid?
- A. Milk
- B. Bananas
- C. Yogurt
- D. Cured meats
Correct answer: D
Rationale: The correct answer is D: Cured meats. Cured meats contain tyramine, which can lead to a hypertensive crisis in clients taking tranylcypromine. Bananas, milk, and yogurt do not contain significant amounts of tyramine and are safe for clients taking this medication. Therefore, the nurse should instruct the client to avoid cured meats to prevent adverse effects.
3. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has a fractured femur and reports feeling short of breath.
- B. A client who is postoperative and has abdominal distention.
- C. A client who is receiving IV fluids and has a temperature of 38.5°C (101.3°F).
- D. A client who has cancer and has been receiving radiation therapy.
Correct answer: A
Rationale: The correct answer is A. A client with a fractured femur and reports feeling short of breath is at risk for a fat embolism, which is a medical emergency. The nurse should assess this client first to rule out this serious complication. Choice B may indicate paralytic ileus, which is important but not immediately life-threatening compared to a fat embolism. Choice C has a fever, which indicates infection but is not as urgent as a potential fat embolism. Choice D, a client receiving radiation therapy, is not experiencing an acute, life-threatening complication that requires immediate assessment compared to a fat embolism.
4. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Insert a tongue depressor into the client's mouth.
- B. Restrain the client's arms and legs.
- C. Turn the client onto their side.
- D. Place the client in a prone position.
Correct answer: C
Rationale: During a tonic-clonic seizure, the nurse should turn the client onto their side. This action helps maintain an open airway by allowing saliva or any vomitus to drain out of the mouth, reducing the risk of aspiration. Inserting a tongue depressor (choice A) is incorrect as it can cause injury to the client's mouth and is not recommended during a seizure. Restraining the client's arms and legs (choice B) can lead to physical harm and should be avoided. Placing the client in a prone position (choice D) is dangerous as it can obstruct the airway and hinder breathing, which is not suitable for a client experiencing a seizure.
5. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?
- A. First-degree AV block.
- B. Premature ventricular contraction.
- C. Sinus bradycardia.
- D. Atrial fibrillation.
Correct answer: A
Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.
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