ATI RN
ATI Exit Exam 2024
1. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following findings should the nurse identify as the cause of late decelerations?
- A. Fetal head compression
- B. Uteroplacental insufficiency
- C. Umbilical cord compression
- D. Fetal hypoxia
Correct answer: B
Rationale: Late decelerations in the fetal heart rate are caused by uteroplacental insufficiency, which results from inadequate blood flow to the placenta. This leads to reduced oxygen and nutrients reaching the fetus during contractions. Choice A, fetal head compression, does not typically cause late decelerations but can result in variable decelerations. Choice C, umbilical cord compression, usually leads to variable decelerations. Choice D, fetal hypoxia, is a broad term and not the direct cause of late decelerations, which are specifically linked to uteroplacental insufficiency.
2. A nurse is preparing to administer vancomycin IV to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
- A. Administer the medication over 60 minutes
- B. Monitor the client's blood glucose level during administration
- C. Infuse the medication rapidly to reduce the risk of infection
- D. Administer the medication using a filter needle
Correct answer: A
Rationale: The correct action the nurse should take is to administer the medication over 60 minutes. This is important because administering vancomycin over 60 minutes helps prevent red man syndrome, a reaction that can occur with rapid infusion. Monitoring the client's blood glucose level (Choice B) is unrelated to vancomycin administration. Infusing the medication rapidly (Choice C) is incorrect and can lead to adverse reactions. Administering the medication using a filter needle (Choice D) is unnecessary for vancomycin administration.
3. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?
- A. Let's talk about how you can change your response to stress.
- B. We should establish our roles in the initial session.
- C. Let me show you simple relaxation exercises to manage stress.
- D. We should discuss resources to implement in your daily life.
Correct answer: B
Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.
4. A nurse is caring for a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Decreased bilirubin levels
- B. Decreased prothrombin time
- C. Decreased albumin levels
- D. Increased prothrombin time
Correct answer: D
Rationale: In clients with cirrhosis, the liver is unable to produce clotting factors efficiently, leading to impaired clotting function. Therefore, an increased prothrombin time is expected in cirrhosis. Choices A, B, and C are incorrect. Decreased bilirubin levels are not typically seen in cirrhosis; prothrombin time is usually increased, not decreased; and albumin levels are often decreased in cirrhosis due to reduced synthetic liver function.
5. A client is receiving discharge teaching for a new prescription of digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will stop taking this medication if my heart rate is below 80/min.
- B. I should take my pulse before taking this medication.
- C. I should stop taking this medication if my pulse is above 100/min.
- D. I will take this medication with an antacid.
Correct answer: B
Rationale: The correct answer is B. Clients taking digoxin should check their pulse before each dose to ensure it is within the appropriate range. Option A is incorrect because stopping the medication based solely on a heart rate below 80/min is not recommended. Option C is incorrect as having a pulse above 100/min doesn't necessarily indicate a need to stop digoxin. Option D is incorrect because digoxin should not be taken with an antacid as it can interfere with its absorption.
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