ATI RN
ATI Medical Surgical Proctored Exam
1. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct answer: C
Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.
2. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct answer: A
Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.
3. A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct answer: D
Rationale: Obtaining information about a client's occupation and hobbies is crucial when assessing respiratory status as many respiratory problems can result from chronic exposure to inhalation irritants related to these activities. Understanding the client's potential exposure can help the healthcare professional identify risk factors and provide appropriate interventions to promote respiratory health.
4. When caring for a client with acute renal failure, which laboratory value is most important to monitor?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum chloride
Correct answer: B
Rationale: In acute renal failure, monitoring serum potassium is crucial because impaired kidney function can lead to hyperkalemia, which can result in life-threatening cardiac dysrhythmias. Elevated potassium levels need close monitoring and prompt interventions to prevent serious complications.
5. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?
- A. Encourage the client to walk for 5 minutes each hour.
- B. Refer the client for smoking cessation classes.
- C. Teach the client about factor V Leiden testing.
- D. Explain to the client that sometimes no cause for the disease is found.
Correct answer: C
Rationale: The most appropriate action for the nurse in this scenario is to teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including pulmonary embolism (PE). In a case where a client has no known risk factors for PE, testing for this genetic disorder is crucial to determine if it is a contributing factor. Encouraging the client to walk or referring them to smoking cessation classes, while beneficial for overall health, are not directly relevant to the development of a PE in this specific case. While it is true that sometimes no cause for a disease is found, prematurely assuming this without appropriate investigations may lead to missed opportunities for preventive measures or treatments.
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