ATI RN
ATI Exit Exam 2024
1. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?
- A. Offer fluids every 2 hours.
- B. Document the client's behavior prior to being placed in seclusion.
- C. Discuss with the client their inappropriate behavior prior to seclusion.
- D. Assess the client's behavior every hour.
Correct answer: B
Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.
2. A client who has a prescription for insulin glargine is talking to a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will mix this insulin with my regular insulin before injecting it.
- B. I will store this insulin in the refrigerator after opening it.
- C. I will take this insulin twice a day.
- D. I will inject this insulin when my blood glucose is above 200 mg/dL.
Correct answer: B
Rationale: The correct answer is B because insulin glargine should be stored in the refrigerator after opening to maintain its potency. Choice A is incorrect as insulin glargine should not be mixed with other insulins. Choice C is incorrect because insulin glargine is typically taken once a day. Choice D is incorrect because insulin glargine is usually taken regardless of blood glucose levels.
3. A nurse in a mental health facility is caring for a client who is angry and throwing objects at staff members. Which of the following actions should the nurse take?
- A. Ask the client to identify what made them angry.
- B. Instruct the client to calm down.
- C. Place the client in seclusion.
- D. Encourage the client to attend group therapy.
Correct answer: C
Rationale: During a situation where a client is exhibiting violent behavior like throwing objects and posing a risk to themselves and others, the immediate priority is to ensure the safety of all involved. Placing the client in seclusion is a necessary intervention to prevent harm and allow for de-escalation. Asking the client to identify the trigger or instructing them to calm down may not be effective or safe in this escalated state. Encouraging the client to attend group therapy is not suitable when they are in an agitated and aggressive state that requires immediate intervention.
4. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse include?
- A. The cord stump will fall off in 5 days.
- B. Contact the provider if the cord stump turns black.
- C. Clean the base of the cord with hydrogen peroxide daily.
- D. Keep the cord stump dry until it falls off.
Correct answer: D
Rationale: The correct instruction for cord care is to keep the cord stump dry until it falls off. This helps prevent infection and promotes healing. Choice A is incorrect because the timing of when the cord stump falls off can vary, usually between 1-3 weeks. Choice B is incorrect as a black cord stump can be a normal part of the healing process, so it is unnecessary to contact the provider for this reason. Choice C is incorrect because cleaning the cord with hydrogen peroxide daily is not recommended as it can delay healing and cause irritation.
5. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?
- A. Apply the patch to the same location each time.
- B. Rotate the patch site daily to avoid skin irritation.
- C. Apply the patch in the morning and remove it at bedtime.
- D. Keep the patch on at all times, even during a bath.
Correct answer: C
Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.
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