ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Pain rating of 4 on a scale of 0 to 10
- C. Respiratory rate of 10/min
- D. Temperature of 37.2°C (99°F)
Correct answer: C
Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.
2. 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.
3. 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.
4. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?
- A. Position the client's legs in adduction
- B. Place a pillow between the client's legs when turning
- C. Keep the client in a low Fowler's position
- D. Turn the client onto the affected side
Correct answer: B
Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.
5. 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.
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