ATI RN
ATI Exit Exam
1. 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.
2. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?
- A. Prothrombin time (PT)
- B. International Normalized Ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Fibrinogen levels
Correct answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.
3. A client with a history of heart failure is receiving furosemide. Which of the following laboratory values should the nurse monitor?
- A. Sodium 140 mEq/L
- B. Calcium 9.0 mg/dL
- C. Potassium 3.2 mEq/L
- D. Chloride 100 mEq/L
Correct answer: C
Rationale: The correct answer is C: Potassium 3.2 mEq/L. A potassium level of 3.2 mEq/L is below the normal range and should be monitored in clients receiving furosemide due to the risk of hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. Choices A, B, and D are not directly impacted by furosemide therapy in the same way as potassium levels, making them less relevant for monitoring in this scenario.
4. A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. "You can take this medication with a full glass of water."
- B. "You should store this medication in the refrigerator."
- C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
- D. "You should avoid eating foods high in sodium while taking this medication."
Correct answer: C
Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.
5. A nurse is assessing a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?
- A. Gastric residual of 200 mL
- B. Heart rate of 100/min
- C. Urinary output of 250 mL in 12 hr
- D. Blood glucose level of 180 mg/dL
Correct answer: D
Rationale: The correct answer is D. A blood glucose level of 180 mg/dL is higher than expected and should be reported to prevent hyperglycemia complications. High blood glucose levels can lead to hyperglycemia, causing various issues such as increased risk of infection and delayed wound healing. Choices A, B, and C are within normal limits for a client receiving continuous enteral feedings and do not require immediate reporting.
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