ATI RN
ATI RN Comprehensive Exit Exam
1. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Apply a moisture barrier ointment.
Correct answer: D
Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.
2. What is the most effective intervention for a patient experiencing acute pain?
- A. Administer analgesics
- B. Reposition the patient
- C. Provide non-pharmacological interventions
- D. Administer IV fluids
Correct answer: A
Rationale: Administering analgesics is the most effective intervention for a patient experiencing acute pain as it directly targets the pain receptors and provides relief. Repositioning the patient may help in some cases, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management but might not provide immediate relief. Administering IV fluids is not a standard intervention for acute pain unless dehydration is contributing to the pain.
3. What is the appropriate action when a patient experiences an allergic reaction to a medication?
- A. Administer epinephrine
- B. Discontinue the medication
- C. Administer corticosteroids
- D. Administer antihistamines
Correct answer: A
Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for a severe allergic reaction as it helps to constrict blood vessels, increase heart rate, and open airways, thereby improving breathing and circulation. Discontinuing the medication may not be sufficient to manage a severe allergic reaction as the allergen is already in the patient's system. Corticosteroids and antihistamines can be considered as complementary treatments but are not the primary immediate intervention required for a severe allergic reaction.
4. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?
- A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
- B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
- C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
- D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Correct answer: D
Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.
5. A nurse is reviewing the prescription for doxazosin with a client. Which of the following should be included in the teaching?
- A. Decrease caloric intake to prevent weight gain.
- B. Increase dietary fiber to alleviate constipation.
- C. Rise slowly when sitting up from bed.
- D. Take this medication in the morning.
Correct answer: C
Rationale: The correct answer is C. Doxazosin can cause orthostatic hypotension, leading to dizziness and falls if the client rises quickly from a seated position. Instructing the client to rise slowly when sitting up from bed helps prevent these adverse effects. Choices A, B, and D are incorrect because doxazosin does not directly relate to caloric intake, dietary fiber, or a specific time of day for administration.
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