ATI RN
ATI RN Comprehensive Exit Exam 2023
1. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Apply a dry dressing.
- B. Cleanse the wound with normal saline.
- C. Perform debridement as needed.
- D. Apply a hydrocolloid dressing.
Correct answer: D
Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.
2. How should a healthcare professional assess for fluid overload in a patient with heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor blood pressure
- D. Check oxygen saturation
Correct answer: A
Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.
3. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?
- A. Calcium level of 9.0 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Respiratory rate of 18/min
- D. Stridor
Correct answer: D
Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.
4. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?
- A. The client's urine output decreases.
- B. The client's blood pressure increases.
- C. The client's heart rate increases.
- D. The client's urine specific gravity decreases.
Correct answer: A
Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.
5. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?
- A. Heart rate of 90/min
- B. Blood pressure of 118/76 mm Hg
- C. Warmth and redness in the calf
- D. Pink-tinged urine
Correct answer: C
Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.
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