ATI RN
ATI Exit Exam
1. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Administer ibuprofen 400 mg PO
- B. Administer oxycodone 10 mg PO
- C. Reposition the client to the unaffected side
- D. Apply a cold compress to the affected knee
Correct answer: B
Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.
2. A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?
- A. Potassium 5.0 mEq/L
- B. Blood pressure 136/84 mm Hg
- C. Sodium 140 mEq/L
- D. Calcium 9.5 mg/dL
Correct answer: A
Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.
3. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
- A. Do you understand that the voices are not real?
- B. Why do you think the voices are talking to you?
- C. Have you tried going to a private place when this occurs?
- D. What helps you ignore what you are hearing?
Correct answer: D
Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.
4. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should avoid using salt substitutes while taking this medication.
- B. I should take this medication with food to prevent nausea.
- C. I should increase my intake of potassium-rich foods while taking this medication.
- D. I should limit my fluid intake while taking this medication.
Correct answer: A
Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.
5. A client who is at 36 weeks of gestation is scheduled for a nonstress test (NST). Which of the following statements by the client indicates an understanding of the teaching?
- A. I should fast for 12 hours before the test.
- B. I should expect the test to take about 10 minutes.
- C. I should have a full bladder for this test.
- D. I will need to have my blood glucose checked before the test.
Correct answer: B
Rationale: The correct answer is B. The nonstress test typically takes about 10 minutes and evaluates the fetal heart rate in response to fetal movement. Having a full bladder or fasting for 12 hours is not required for a nonstress test. Checking blood glucose levels is not part of the nonstress test procedure.
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