ATI RN
ATI Exit Exam 2024
1. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?
- A. Assist the client in changing positions in bed
- B. Administer a PRN dose of morphine
- C. Encourage the client to use relaxation techniques
- D. Offer the client a back massage
Correct answer: B
Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.
2. A nurse is caring for a client following the application of a cast. Which of the following actions should the nurse take first?
- A. Place an ice pack over the cast
- B. Palpate the pulse distal to the cast
- C. Teach the client to keep the cast clean and dry
- D. Position the casted extremity on a pillow
Correct answer: B
Rationale: Palpating the pulse distal to the cast is the priority as it assesses for circulation. Ensuring adequate blood flow is essential to prevent complications such as compartment syndrome. Placing an ice pack over the cast could cause constriction of blood vessels, further compromising circulation. Teaching the client about cast care and positioning the casted extremity on a pillow are important but do not take precedence over assessing circulation.
3. A healthcare provider is providing dietary teaching to a client who has a new diagnosis of hypertension. Which of the following foods should the provider recommend?
- A. Bananas
- B. Whole grains
- C. Lean beef
- D. Canned soup
Correct answer: C
Rationale: The correct answer is lean beef because it is a good source of protein and essential nutrients. When providing dietary recommendations to clients with hypertension, it is important to focus on lean protein sources to promote a balanced diet. Bananas, although a healthy fruit, may not be the best choice due to their high potassium content, which can sometimes be a concern for individuals with hypertension. Whole grains are generally a good choice, but lean protein like beef is more suitable in this scenario. Canned soup often contains high levels of sodium, which is not recommended for individuals with hypertension.
4. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should consider taking a sleeping pill before bed each night.
- C. It must be difficult taking care of someone who is terminally ill.
- D. You are doing a great job taking care of your mother.
Correct answer: A
Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.
5. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Blood pressure of 130/85 mm Hg
- C. Coughing up small amounts of sputum
- D. Absent gag reflex
Correct answer: D
Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.
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