ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?
- A. Administer the injection into the muscle of your thigh.
- B. Pinch the skin before inserting the needle.
- C. Rub the injection site after administering the medication.
- D. Administer the injection into the fat tissue of your abdomen.
Correct answer: D
Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.
2. A nurse is reviewing the laboratory values of a client who has liver cirrhosis. Which of the following findings should the nurse report to the provider?
- A. Bilirubin 0.8 mg/dL
- B. Ammonia 35 mcg/dL
- C. Prothrombin time 16 seconds
- D. Albumin 4 g/dL
Correct answer: C
Rationale: In clients with liver cirrhosis, an elevated prothrombin time indicates impaired liver function and decreased production of clotting factors. This finding should be reported to the provider for further evaluation and management. Choices A, B, and D are within normal ranges and do not specifically indicate worsening liver cirrhosis. Bilirubin 0.8 mg/dL is normal, ammonia 35 mcg/dL is within the reference range, and albumin 4 g/dL is also within the normal range for this client population.
3. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?
- A. Administer the medication over 30 minutes.
- B. Monitor the client for a decrease in blood pressure during administration.
- C. Assess the IV site for infiltration during administration.
- D. Premedicate the client with an antiemetic prior to administration.
Correct answer: C
Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.
4. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following sites should the healthcare provider select?
- A. Deltoid
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular injections in adults due to its large muscle mass and low risk of complications. The deltoid, although a common site for vaccines, has a smaller muscle mass and may not be suitable for all types of medications. The rectus femoris is a muscle in the thigh that is more commonly used for intramuscular injections in infants. The dorsogluteal site is no longer recommended due to its proximity to major nerves and blood vessels.
5. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?
- A. Low back pain
- B. Dyspnea
- C. Hypotension
- D. Thready pulse
Correct answer: B
Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.
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