ATI RN
ATI Exit Exam 2023
1. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct answer: C
Rationale: The correct action the nurse should include for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent constipation, straining, and subsequent bleeding, which is crucial for clients with thrombocytopenia. Encouraging the client to floss daily (Choice A) is important for oral hygiene but not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems to reduce the risk of foodborne illnesses but is not directly related to thrombocytopenia management.
2. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?
- A. Place the client upright on a donut-shaped cushion.
- B. Teach the client to shift his weight every 15 minutes while sitting.
- C. Turn and reposition the client every 3 hours.
- D. Assess pressure points every 24 hours.
Correct answer: B
Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.
3. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider?
- A. Heart rate 140/min.
- B. A bulging anterior fontanel.
- C. Respiratory rate 50/min.
- D. Blood glucose 45 mg/dL.
Correct answer: D
Rationale: A blood glucose level of 45 mg/dL is below the normal range for a newborn and indicates hypoglycemia, which can lead to serious complications if left untreated. Therefore, this finding should be reported to the provider immediately. Choices A, B, and C are within normal ranges for a newborn and do not require immediate reporting. A heart rate of 140/min, a bulging anterior fontanel, and a respiratory rate of 50/min are all common findings in a newborn and do not raise immediate concerns.
4. A client is receiving radiation therapy for cancer. Which of the following skin care instructions should the nurse include in the teaching?
- A. Apply alcohol-free lotions to your skin to prevent dryness.
- B. Avoid exposing the irradiated area to direct sunlight.
- C. Cleanse the irradiated area with mild soap and water.
- D. Apply ice packs to the irradiated area to prevent swelling.
Correct answer: B
Rationale: The correct answer is to avoid exposing the irradiated area to direct sunlight. Direct sunlight can further damage the skin during radiation therapy. Choice A is incorrect because alcohol-based lotions can irritate the skin further. Choice C is incorrect because mild soap and water can be drying to the skin. Choice D is incorrect because applying ice packs can cause additional skin damage during radiation therapy.
5. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?
- A. Sodium 144 mEq/L
- B. Potassium 5.2 mEq/L
- C. Bicarbonate 24 mEq/L
- D. Magnesium 1.9 mEq/L
Correct answer: B
Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.
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