ATI RN
ATI Exit Exam RN
1. What is the most appropriate action when a patient experiences chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Reposition the patient
- D. Prepare for surgery
Correct answer: A
Rationale: Administering aspirin is the correct initial action when a patient experiences chest pain. Aspirin helps reduce the risk of clot formation and is a standard first-line treatment for chest pain related to possible cardiac issues. Administering nitroglycerin may be appropriate based on the underlying cause of chest pain, but aspirin is typically administered first. Repositioning the patient is not the primary intervention for chest pain, and preparing for surgery is not the immediate action required unless indicated by a healthcare provider after assessment.
2. A client is receiving a new prescription for enoxaparin. Which of the following instructions should the nurse include?
- A. Rub the injection site after administration.
- B. Pinch the skin while administering the injection.
- C. Aspirate before administering the medication.
- D. Avoid taking aspirin while using this medication.
Correct answer: D
Rationale: The correct answer is D: 'Avoid taking aspirin while using this medication.' Enoxaparin is an anticoagulant medication, and taking aspirin concurrently can increase the risk of bleeding. Choices A, B, and C are incorrect. A nurse should not instruct the client to rub the injection site after administration as it may cause irritation. Pinching the skin while administering the injection is not recommended for enoxaparin injections. Aspirating before administering the medication is also unnecessary as enoxaparin is administered subcutaneously, not intramuscularly.
3. A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hypotension
- C. Dry mucous membranes
- D. Tachypnea
Correct answer: C
Rationale: Correct! Dry mucous membranes are a common finding in clients with dehydration. Dehydration leads to reduced fluid volume in the body, resulting in dryness of mucous membranes, decreased skin turgor, and thirst. Bradycardia (slow heart rate) is not typically associated with dehydration, as the body tries to compensate for decreased fluid volume by increasing heart rate. Hypotension (low blood pressure) is a possible finding in dehydration due to reduced circulating volume. Tachypnea (rapid breathing) is more commonly seen in conditions like respiratory distress or metabolic acidosis, rather than dehydration.
4. Which of the following actions is appropriate when administering a blood transfusion?
- A. Verify patient identity
- B. Administer medication
- C. Monitor vital signs
- D. Start blood transfusion without verification
Correct answer: A
Rationale: Verifying the patient's identity is a critical step when administering a blood transfusion to ensure that the correct blood product is given to the right patient. This process helps prevent errors and enhances patient safety. Choice B, 'Administer medication,' is incorrect because the focus during a blood transfusion should be on ensuring the correct blood product is administered. Choice C, 'Monitor vital signs,' is also important but comes after verifying the patient's identity. Choice D, 'Start blood transfusion without verification,' is incorrect and unsafe as patient identification verification is essential prior to starting any medical procedure, especially one as important as a blood transfusion.
5. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?
- A. Platelets 250,000/mm³
- B. aPTT 60 seconds
- C. Hemoglobin 15 g/dL
- D. INR 1.5
Correct answer: B
Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.
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