ATI RN
ATI Exit Exam 2023
1. A nurse is reviewing the medical records of a client with chronic heart failure. What dietary recommendation should the nurse make?
- A. Follow a 3g sodium diet.
- B. Drink at least 3 liters of fluid per day.
- C. Place the client's lower extremities on two pillows.
- D. Maintain the client's oxygen saturation at 89%.
Correct answer: A
Rationale: The correct answer is A: Follow a 3g sodium diet. For clients with chronic heart failure, limiting sodium intake is crucial to prevent fluid retention and exacerbation of heart failure symptoms. High sodium intake can lead to fluid buildup, causing the heart to work harder. Choices B, C, and D are incorrect. Drinking excessive fluid can worsen fluid retention in heart failure, elevating the workload of the heart. Placing the client's lower extremities on two pillows is a positioning intervention to alleviate edema, not a dietary recommendation. Maintaining oxygen saturation at 89% is more related to respiratory status rather than dietary management of chronic heart failure.
2. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
- A. Passing small clots in the urine.
- B. Continuous bladder irrigation.
- C. Red-tinged urine with numerous clots.
- D. Urine output of 50 mL/hr.
Correct answer: C
Rationale: The correct answer is C: Red-tinged urine with numerous clots. This finding should be reported because it indicates excessive bleeding following a TURP procedure. Passing small clots in the urine (choice A) is expected post-TURP. Continuous bladder irrigation (choice B) is a standard procedure after TURP to prevent clot retention. Urine output of 50 mL/hr (choice D) is within the expected range postoperatively and does not indicate a complication.
3. A nurse is providing teaching to a client who is postoperative following a cataract extraction. Which of the following statements should the nurse include?
- A. You should expect to have eye pain for the first 2 days after surgery.
- B. You should bend at the waist to pick up objects from the floor.
- C. You should avoid sleeping on the side of the body that was operated on.
- D. You should wear an eye shield at night for 2 weeks.
Correct answer: D
Rationale: The correct answer is D. After cataract surgery, wearing an eye shield at night for 2 weeks is essential to protect the eye during the initial healing period. Choice A is incorrect because significant eye pain should not be expected for the first 2 days after surgery. Choice B is incorrect as bending at the waist can increase intraocular pressure, which should be avoided postoperatively. Choice C is incorrect as there is no need to avoid sleeping on the side of the body that was operated on after cataract surgery.
4. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?
- A. Flush the tube with 10 mL of water after feeding
- B. Flush the tube with 30 mL of water before feeding
- C. Place the client in a left lateral position
- D. Place the feeding bag 61 cm (24 in) above the client's abdomen
Correct answer: B
Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.
5. A healthcare provider is caring for a client who has been diagnosed with sepsis. Which of the following laboratory results indicates that the client is developing disseminated intravascular coagulation (DIC)?
- A. Elevated hemoglobin
- B. Elevated white blood cell count
- C. Decreased fibrinogen level
- D. Decreased platelet count
Correct answer: D
Rationale: The correct answer is D, decreased platelet count. In disseminated intravascular coagulation (DIC), there is widespread activation of clotting factors leading to the formation of multiple blood clots throughout the body, which can deplete platelets. A decreased platelet count is a hallmark of DIC. Elevated hemoglobin (choice A) and elevated white blood cell count (choice B) are not specific indicators of DIC. While fibrinogen levels (choice C) can be decreased in DIC due to consumption, a decreased platelet count is a more specific and early sign of DIC development.
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