ATI RN
ATI Exit Exam 180 Questions Quizlet
1. 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.
2. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis and is prescribed methotrexate. Which of the following results should the nurse report to the provider?
- A. White blood cell count 8,000/mm3
- B. Platelet count 150,000/mm3
- C. Hemoglobin 14 g/dL
- D. Aspartate aminotransferase (AST) 60 units/L
Correct answer: D
Rationale: The correct answer is D: Aspartate aminotransferase (AST) 60 units/L. An elevated AST level indicates liver damage, a side effect of methotrexate, and should be reported. Choices A, B, and C are within normal ranges and do not indicate potential complications related to methotrexate therapy.
3. A nurse is caring for a client who wears glasses. What action should the nurse take?
- A. Store the glasses in a labeled case.
- B. Clean the glasses with hot water.
- C. Clean the glasses with a paper towel.
- D. Store the glasses on the bedside table.
Correct answer: A
Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This helps prevent damage and loss of the glasses, ensuring they are kept safe when not in use. Cleaning the glasses with hot water (choice B) can damage the lenses or frames, while cleaning with a paper towel (choice C) might lead to scratches. Storing the glasses on the bedside table (choice D) increases the risk of misplacement or damage.
4. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
- A. Request a renewal of the prescription every 8 hours.
- B. Check the client's peripheral pulse every 30 minutes.
- C. Obtain a prescription for restraints within 4 hours.
- D. Document the client's condition every 15 minutes.
Correct answer: D
Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.
5. A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?
- A. Monitor the client's vital signs every 4 hours.
- B. Start the transfusion with 0.9% sodium chloride.
- C. Administer the transfusion over 6 hours.
- D. Infuse the first 500 mL of blood over 1 hour.
Correct answer: B
Rationale: The correct answer is B: Start the transfusion with 0.9% sodium chloride. 0.9% sodium chloride is the only IV solution that is compatible with blood products and should be used to prime the tubing before a transfusion. Choice A is incorrect because vital signs should be monitored more frequently, typically every 15 minutes at the beginning of the transfusion. Choice C is incorrect as blood transfusions are usually administered over 2-4 hours, not 6 hours. Choice D is incorrect as the first 500 mL of blood should be infused slowly over 1-2 hours to monitor for any adverse reactions.
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