ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Massage the injection site after administration.
- B. Administer the medication intramuscularly.
- C. Inject the medication into the client's abdomen.
- D. Inject the medication into the deltoid muscle.
Correct answer: C
Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously, not intramuscularly. Massaging the injection site after administration is not recommended as it can cause bruising or discomfort. Injecting the medication into the deltoid muscle is also incorrect because enoxaparin should be given in areas of adipose tissue, such as the abdomen, to ensure proper absorption and effectiveness.
2. 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.
3. A client who is 1 day postpartum plans to breastfeed. Which statement indicates an understanding of the teaching provided by the nurse?
- A. I will breastfeed every 4 hours.
- B. I will feed my baby from each breast for 5 minutes.
- C. I will use both breasts at each feeding.
- D. I will pump my breasts if my baby does not wake up to feed.
Correct answer: C
Rationale: The correct answer is C. Using both breasts at each feeding helps ensure adequate milk production and consumption. Option A is incorrect because breastfeeding should be done on demand rather than following a strict schedule. Option B is incorrect as limiting feeding time to 5 minutes per breast may not provide the baby with enough milk. Option D is also incorrect as pumping should not replace direct breastfeeding unless there is a specific medical reason to do so.
4. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?
- A. Does the doctor know you are eating that?
- B. Why are you eating seaweed soup?
- C. Of course I will heat that up for you.
- D. The hospital food is more nutritious.
Correct answer: C
Rationale: Agreeing to heat up the seaweed soup respects the client's cultural preferences and promotes a positive postpartum experience. Seaweed soup is a traditional food in some cultures, often believed to support recovery and breastfeeding. The nurse's supportive response fosters cultural sensitivity, which is crucial in providing patient-centered care.
5. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?
- A. Check for the presence of bowel sounds every 8 hours.
- B. Flush the NG tube every 24 hours.
- C. Provide the client with sips of water every 2 hours.
- D. Keep the client's head of the bed elevated to 45 degrees.
Correct answer: D
Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.
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