ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. White blood cell count of 9,000/mm3
- C. Temperature of 37.8°C (100°F)
- D. Blood pressure of 118/78 mm Hg
Correct answer: C
Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.
2. A nurse is caring for a client who has cirrhosis. Which of the following laboratory values should the nurse expect to be elevated?
- A. Serum albumin.
- B. Ammonia.
- C. Bilirubin.
- D. Prothrombin time.
Correct answer: B
Rationale: The correct answer is B: Ammonia. In clients with cirrhosis, impaired liver function can lead to elevated levels of ammonia in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a condition characterized by altered mental status. Serum albumin (Choice A) is typically decreased in cirrhosis due to the liver's reduced synthetic function. Bilirubin (Choice C) levels can be elevated in liver disease but may not always be the most specific marker for cirrhosis. Prothrombin time (Choice D) is prolonged in cirrhosis due to impaired liver synthesis of clotting factors.
3. 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.
4. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?
- A. Provide information about stress management.
- B. Maintain a warm temperature in the client's room.
- C. Administer epinephrine for acute episodes.
- D. Give glucocorticoid steroids twice a day.
Correct answer: A
Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.
5. A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take?
- A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice
- B. Tell staff to explain procedures to clients before obtaining informed consent
- C. Instruct unit staff to share personal experiences to help clients make decisions
- D. Develop a system for staff members to report safety concerns in the client care environment
Correct answer: D
Rationale: The correct answer is D. Developing a system for staff members to report safety concerns in the client care environment is crucial to promoting client advocacy and ensuring client safety. This action empowers staff to identify and address potential safety issues, ultimately enhancing the quality of care provided. Choices A, B, and C are incorrect. Choice A suggests implementing paternalism, which involves making decisions for clients without their input, contradicting the principles of client advocacy. Choice B focuses on informed consent procedures, which are important but do not directly relate to promoting client advocacy among staff. Choice C, sharing personal experiences, may not always align with professional boundaries and can potentially bias clients' decision-making processes.
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