ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 140/90 mm Hg
- B. Heart rate of 88/min
- C. LDL cholesterol 110 mg/dL
- D. Respiratory rate of 16/min
Correct answer: D
Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.
2. A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?
- A. Monitor the client's vital signs every 4 hours.
- B. Start the transfusion with 0.9% sodium chloride.
- C. Administer the transfusion over 6 hours.
- D. Infuse the first 500 mL of blood over 1 hour.
Correct answer: B
Rationale: The correct answer is B: Start the transfusion with 0.9% sodium chloride. 0.9% sodium chloride is the only IV solution that is compatible with blood products and should be used to prime the tubing before a transfusion. Choice A is incorrect because vital signs should be monitored more frequently, typically every 15 minutes at the beginning of the transfusion. Choice C is incorrect as blood transfusions are usually administered over 2-4 hours, not 6 hours. Choice D is incorrect as the first 500 mL of blood should be infused slowly over 1-2 hours to monitor for any adverse reactions.
3. 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.
4. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?
- A. Store the glasses in a labeled case
- B. Clean the glasses with hot water
- C. Clean the glasses with a paper towel
- D. Store the glasses on the bedside table
Correct answer: A
Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This ensures the safety of the glasses and helps in their proper identification when needed. Cleaning the glasses with hot water (Choice B) can damage them, and using a paper towel (Choice C) can scratch the lenses. Storing the glasses on the bedside table (Choice D) can lead to misplacement or damage. Therefore, the most appropriate action is to store the glasses in a labeled case.
5. 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.
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