ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Potassium 4.0 mEq/L
- B. Calcium 9.5 mg/dL
- C. Heart rate of 60/min
- D. Sodium 140 mEq/L
Correct answer: C
Rationale: The correct answer is C: Heart rate of 60/min. A heart rate of 60/min is borderline bradycardia, which can be a sign of digoxin toxicity. Digoxin can cause bradycardia, so any further decrease in heart rate should be reported promptly to the healthcare provider. Choices A, B, and D are within the normal range and not specifically related to potential digoxin toxicity, so they do not require immediate reporting.
2. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?
- A. Platelet count 150,000/mm³
- B. aPTT 30 seconds
- C. Sodium 140 mEq/L
- D. Serum creatinine 3.0 mg/dL
Correct answer: D
Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.
3. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?
- A. Calf tenderness.
- B. Shortness of breath.
- C. Elevated blood pressure.
- D. Respiratory rate of 18/min.
Correct answer: B
Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.
4. 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.
5. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?
- A. Clamp the chest tube when assisting the client out of bed.
- B. Empty the drainage system every 8 hours.
- C. Keep the collection device below the client's chest.
- D. Strip the chest tube every 4 hours.
Correct answer: C
Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.
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