ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Fetal heart rate of 110/min
- B. 1+ pitting edema
- C. Blood pressure 138/80 mm Hg
- D. Urine output of 20 mL/hr
Correct answer: D
Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.
2. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?
- A. Encourage the client to spend time in the day room.
- B. Withdraw the client's TV privileges if they do not attend group therapy.
- C. Encourage the client to take frequent rest periods.
- D. Place the client in seclusion when they exhibit signs of anxiety.
Correct answer: C
Rationale: Encouraging the client to take frequent rest periods is the appropriate intervention when caring for a client with bipolar disorder experiencing mania. During manic episodes, individuals often exhibit hyperactivity and may become exhausted. Rest periods can help reduce these symptoms. Choices A, B, and D are incorrect. Spending time in the day room may not address the client's need for rest, withdrawing TV privileges is not directly related to managing mania symptoms, and placing the client in seclusion when anxious can escalate the situation rather than promoting a calming environment.
3. A nurse is providing dietary teaching to a client who has a new diagnosis of chronic kidney disease. Which of the following foods should the nurse instruct the client to avoid?
- A. Baked chicken
- B. Bananas
- C. Lean cuts of beef
- D. Canned soup
Correct answer: D
Rationale: The correct answer is D: Canned soup. Canned soups are typically high in sodium, which can lead to fluid retention in clients with chronic kidney disease. Sodium restriction is crucial in managing this condition. Choice A, baked chicken, is a lean protein source that is generally recommended for individuals with kidney disease. Bananas (Choice B) are high in potassium, so clients with kidney disease may need to limit their intake depending on their individual treatment plan. Lean cuts of beef (Choice C) can be a good source of protein and iron for clients with kidney disease as long as portion sizes are controlled to manage protein intake.
4. A client has a new prescription for digoxin. Which of the following statements should the nurse include?
- A. You should take this medication on an empty stomach.
- B. You should avoid taking this medication with antacids.
- C. Take your pulse before taking this medication.
- D. You should contact your provider if you experience visual changes.
Correct answer: C
Rationale: The correct statement for the nurse to include when teaching a client about digoxin is to 'Take your pulse before taking this medication.' This is essential because clients taking digoxin need to monitor their pulse to detect signs of bradycardia, a common adverse effect of the medication. Option A is incorrect because digoxin is usually recommended to be taken with food to avoid gastrointestinal upset. Option B is incorrect because antacids can interfere with the absorption of digoxin. Option D is incorrect because contacting the provider for visual changes is important, but monitoring the pulse is crucial for digoxin administration.
5. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?
- A. Place the cap from the solution sterile side up on a clean surface.
- B. Open the outermost flap of the sterile kit away from the body.
- C. Place the sterile dressing within 1.25 cm of the edge of the sterile field.
- D. Set up the sterile field 5 cm below waist level.
Correct answer: B
Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.
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