ATI RN
ATI Exit Exam 2023 Quizlet
1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as an indication of a hemolytic transfusion reaction?
- A. Low back pain.
- B. Bradycardia.
- C. Chills.
- D. Distended neck veins.
Correct answer: A
Rationale: The correct answer is A: Low back pain. Low back pain is a common sign of a hemolytic transfusion reaction, indicating the destruction of red blood cells. This finding requires immediate intervention as it can lead to serious complications such as renal failure. Bradycardia (choice B) is not typically associated with a hemolytic transfusion reaction. Chills (choice C) can be seen in febrile non-hemolytic transfusion reactions. Distended neck veins (choice D) are more indicative of fluid overload rather than a hemolytic reaction.
2. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by assessing which of the following?
- A. A chest x-ray reveals increased density in all lung fields
- B. The client reports feeling less anxious
- C. Diminished breath sounds are auscultated unilaterally
- D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg
Correct answer: B
Rationale: The correct answer is B. Client-reported improvement in anxiety is an indication of effective treatment for pulmonary embolism. Choice A is incorrect as increased density in all lung fields on a chest x-ray may indicate complications or lack of improvement. Choice C is incorrect as diminished breath sounds auscultated unilaterally may suggest a localized lung issue and not necessarily reflect the effectiveness of treatment for a pulmonary embolism. Choice D is incorrect as the ABG results provided do not specifically indicate the effectiveness of treatment for a pulmonary embolism.
3. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Peripheral edema.
- B. Cough with frothy sputum.
- C. Jugular vein distention.
- D. Dependent edema.
Correct answer: C
Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.
4. A nurse is caring for a client who has a new diagnosis of deep-vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Massage the affected leg to relieve discomfort
- B. Place a heating pad on the affected leg
- C. Encourage the client to walk around frequently
- D. Monitor the client's oxygen saturation level
Correct answer: D
Rationale: The correct answer is to monitor the client's oxygen saturation level. Deep-vein thrombosis (DVT) increases the risk of pulmonary embolism, a life-threatening complication. Monitoring oxygen saturation helps in early detection of any signs of compromised respiratory function. Massaging the affected leg can dislodge a blood clot, leading to severe consequences. Applying heat through a heating pad can promote vasodilation and increase the risk of clot dislodgment. While mobility is essential in preventing DVT complications, encouraging excessive walking without proper assessment can potentially dislodge a clot and worsen the condition.
5. A healthcare professional is assessing a client receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the healthcare professional identify as an adverse effect of the medication?
- A. Diarrhea.
- B. Urinary retention.
- C. Hypotension.
- D. Bradycardia.
Correct answer: C
Rationale: Hypotension is a common adverse effect of morphine due to its vasodilatory properties. It can lead to a drop in blood pressure, which should be closely monitored during administration. Diarrhea (Choice A) is not a typical adverse effect of morphine. Urinary retention (Choice B) is a side effect of morphine due to its impact on the bladder muscles, but it is not classified as an adverse effect. Bradycardia (Choice D) is not a common adverse effect of morphine; instead, it tends to cause tachycardia.
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