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 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 Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.
3. A nurse is assessing a client who has myasthenia gravis. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Increased muscle strength.
- C. Diarrhea.
- D. Decreased deep tendon reflexes.
Correct answer: D
Rationale: The correct answer is D: Decreased deep tendon reflexes. In myasthenia gravis, muscle weakness is a common manifestation, leading to decreased deep tendon reflexes. Bradycardia (choice A) is not typically associated with myasthenia gravis. Increased muscle strength (choice B) is unlikely as muscle weakness is a hallmark of this condition. Diarrhea (choice C) is not a typical finding in myasthenia gravis.
4. 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.
5. 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.
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