ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse take?
- A. Apply a tourniquet above the insertion site
- B. Shave the area around the insertion site
- C. Insert the catheter at a 15-degree angle
- D. Use an 18-gauge needle for insertion
Correct answer: C
Rationale: The correct answer is to insert the catheter at a 15-degree angle. This angle allows for easier venous access by ensuring proper catheter placement into the vein. Applying a tourniquet above the insertion site can help distend the vein for better visualization but is not the immediate action required for the insertion process. Shaving the area around the insertion site is not necessary unless there is excessive hair that may interfere with the insertion. Using an 18-gauge needle for insertion is a specific detail related to the equipment rather than the technique of insertion.
2. 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.
3. A client who had a colon resection and a new ascending colostomy is receiving discharge teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. My stool will become fully formed within 3 weeks.
- B. My skin should be cleaned with alcohol before applying a new pouch.
- C. I should avoid eating popcorn and fresh pineapple.
- D. I should expect bruising around the stoma.
Correct answer: C
Rationale: The correct answer is C because avoiding popcorn and fresh pineapple helps prevent complications with an ascending colostomy. Statements A, B, and D are incorrect. Statement A is inaccurate as it takes time for bowel function to normalize after surgery. Statement B is incorrect as alcohol can be irritating to the skin; gentle soap and water are recommended for cleaning. Statement D is incorrect as bruising around the stoma is not an expected outcome of colostomy creation.
4. A patient is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
- A. Prime IV tubing with 0.9% sodium chloride
- B. Use a 24-gauge IV catheter
- C. Obtain filterless IV tubing
- D. Place blood in the warmer for 1 hour
Correct answer: A
Rationale: Priming the IV tubing with 0.9% sodium chloride is crucial before administering packed RBCs as it prevents hemolysis and ensures the safe transfusion of blood. Using a smaller 20- to 22-gauge IV catheter is recommended for packed RBCs to prevent hemolysis due to the small tubing size and faster flow rate. Obtaining filterless IV tubing is incorrect as blood products should be administered through a specialized filter to prevent potential clots or contaminants from reaching the patient. Placing blood in the warmer for an hour is unnecessary and could lead to overheating, potentially causing harm to the patient.
5. 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.
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