ATI RN
ATI Exit Exam 180 Questions Quizlet
1. 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.
2. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions 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 is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.
3. A nurse is teaching a client who is at 10 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?
- A. This test will confirm whether your baby has a genetic disorder.
- B. Amniocentesis is used to assess your baby's lung maturity.
- C. You should not feel any pain during this procedure.
- D. This test will assess the amount of amniotic fluid around your baby.
Correct answer: A
Rationale: The correct answer is A because amniocentesis is a procedure that confirms genetic disorders by analyzing the amniotic fluid surrounding the baby. Choice B is incorrect because amniocentesis is not used to assess lung maturity. Choice C is incorrect because some discomfort or pain may be felt during the procedure. Choice D is incorrect because amniocentesis does not primarily assess the amount of amniotic fluid around the baby.
4. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis
- B. Administer flumazenil to the client
- C. Evaluate the client for further suicidal behavior
- D. Initiate seizure precautions for the client
Correct answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.
5. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?
- A. Administer the injection into the muscle of your thigh.
- B. Pinch the skin before inserting the needle.
- C. Rub the injection site after administering the medication.
- D. Administer the injection into the fat tissue of your abdomen.
Correct answer: D
Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.
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