ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Peripheral edema.
- B. Bradycardia.
- C. Jugular vein distention.
- D. Dependent edema.
Correct answer: C
Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.
2. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?
- A. Check your oxygen equipment daily for proper function.
- B. Increase the oxygen flow rate if you feel short of breath.
- C. Store your oxygen tanks lying flat on the floor.
- D. It is safe to smoke as long as you are more than 10 feet from the oxygen source.
Correct answer: A
Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.
3. In an emergency department following a community disaster, a healthcare provider is performing triage for multiple clients. To which of the following types of injuries should the provider assign the highest priority?
- A. Below-the-knee amputation.
- B. Fractured tibia.
- C. 95% full-thickness body burn.
- D. 10 cm laceration to the forearm.
Correct answer: A
Rationale: During disaster triage, clients with severe injuries that are immediately life-threatening and have a high likelihood of mortality without intervention are assigned the highest priority. A below-the-knee amputation falls into this category as it indicates a critical injury that requires immediate attention to prevent further complications or loss of life. Fractured tibia, a 95% full-thickness body burn, and a 10 cm laceration to the forearm, while serious, do not pose the same level of immediate life-threatening risk as a below-the-knee amputation in the context of disaster triage.
4. A client who is 14 weeks of gestation reports swelling of the face. What should the nurse do next?
- A. Administer an analgesic.
- B. Report this finding to the provider immediately.
- C. Administer an antiemetic.
- D. Monitor the client's vital signs.
Correct answer: B
Rationale: The correct answer is to report this finding to the provider immediately. Swelling of the face in pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Prompt reporting and intervention are crucial to prevent complications for both the client and the fetus. Administering an analgesic (choice A) is not appropriate for this situation as it does not address the underlying cause of the swelling. Administering an antiemetic (choice C) is used to treat nausea and vomiting, which are not the primary concerns associated with facial swelling in this scenario. Monitoring the client's vital signs (choice D) is important but should be done after reporting the finding to the provider to guide further assessment and management.
5. 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.
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