ATI RN
ATI Exit Exam 180 Questions Quizlet
1. 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.
2. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head covered with a cap.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct answer: C
Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.
3. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?
- A. Administer the medication over 30 minutes.
- B. Monitor the client for a decrease in blood pressure during administration.
- C. Assess the IV site for infiltration during administration.
- D. Premedicate the client with an antiemetic prior to administration.
Correct answer: C
Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.
4. 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.
5. A nurse is reviewing the laboratory results of a client who has Cushing's disease. The nurse should expect an increase in which of the following laboratory values?
- A. Serum glucose level
- B. Serum potassium level
- C. Serum calcium level
- D. Serum sodium level
Correct answer: A
Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is increased cortisol production, leading to elevated blood glucose levels. This occurs due to the role of cortisol in promoting gluconeogenesis and insulin resistance. Choices B, C, and D are incorrect because Cushing's disease is not typically associated with alterations in serum potassium, calcium, or sodium levels.
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