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 teaching a client who has a new prescription for lisinopril. Which of the following statements should the nurse include?
- A. You should expect to develop a dry cough while taking this medication.
- B. This medication can cause a slow heart rate.
- C. You should increase your intake of foods high in potassium.
- D. You should avoid using salt substitutes while taking this medication.
Correct answer: D
Rationale: The correct statement to include when teaching a client prescribed with lisinopril is that they should avoid using salt substitutes while taking this medication. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. Therefore, using salt substitutes that contain potassium can worsen this condition. Choices A, B, and C are incorrect because lisinopril is not typically associated with causing a dry cough or a slow heart rate, and increasing potassium intake can be harmful in the presence of lisinopril-induced hyperkalemia.
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 is receiving packed RBCs. Which of the following actions should the nurse take?
- A. Monitor the client's blood glucose level every hour
- B. Administer the blood using a microdrip set
- C. Assess the client's vital signs every 2 hours
- D. Infuse the blood within 4 hours
Correct answer: D
Rationale: The correct answer is to infuse the blood within 4 hours. This is crucial to prevent bacterial contamination and hemolysis during blood transfusions. Monitoring the client's blood glucose level every hour (Choice A) is not directly related to packed RBC transfusions. Administering the blood using a microdrip set (Choice B) may be appropriate for specific medications but is not a requirement for packed RBC transfusions. Assessing the client's vital signs every 2 hours (Choice C) is important for monitoring the client's overall condition but is not as time-sensitive as ensuring the timely infusion of packed RBCs.
5. A nurse is caring for a client who is 4 hours postoperative following an open reduction and internal fixation of the left tibia. Which of the following findings should the nurse report to the provider?
- A. Serous drainage on the dressing
- B. Capillary refill of 2 seconds
- C. Heart rate of 62/min
- D. Left foot is cool to the touch
Correct answer: D
Rationale: The correct answer is D. A cool left foot indicates impaired circulation, which could be a sign of compartment syndrome or impaired blood flow. This finding should be reported to the provider promptly for further evaluation and intervention. Serous drainage on the dressing is expected postoperatively and is not a concerning finding. A capillary refill of 2 seconds is within the normal range (less than 3 seconds is normal), indicating adequate peripheral perfusion. A heart rate of 62/min is also within the normal range for an adult, suggesting no immediate concern related to the surgery.
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