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 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.
3. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. Glucose 180 mg/dL
- B. Sodium 136 mEq/L
- C. Potassium 3.8 mEq/L
- D. Albumin 3.5 g/dL
Correct answer: A
Rationale: The correct answer is A: "Glucose 180 mg/dL." Elevated glucose levels in a client receiving TPN may indicate hyperglycemia, which can lead to complications such as osmotic diuresis, dehydration, and electrolyte imbalances. It is essential to report this finding to the provider for further evaluation and management. Choices B, C, and D are within normal ranges and do not indicate immediate concerns related to TPN administration.
4. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis
- B. Administer flumazenil to the client
- C. Evaluate the client for further suicidal behavior
- D. Initiate seizure precautions for the client
Correct answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.
5. A client who has a new prescription for alendronate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a full glass of water before breakfast.
- B. I should take this medication with food to prevent gastrointestinal upset.
- C. I should remain upright for at least 30 minutes after taking this medication.
- D. I should avoid taking this medication with antacids.
Correct answer: C
Rationale: The correct answer is C: "I should remain upright for at least 30 minutes after taking this medication." This statement indicates understanding because clients taking alendronate should remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Choice A is incorrect because alendronate should be taken with a full glass of water after waking up, not before breakfast. Choice B is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because alendronate should be taken separately from antacids.
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