ATI RN
ATI RN Comprehensive Exit Exam 2023
1. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 2 minutes with a duration of 90 seconds. Which of the following actions should the nurse take?
- A. Increase the oxytocin infusion.
- B. Maintain the oxytocin infusion.
- C. Discontinue the oxytocin infusion.
- D. Provide reassurance to the client.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. With contractions occurring every 2 minutes and lasting 90 seconds, this pattern indicates hyperstimulation, which can be harmful to the fetus. Discontinuing the oxytocin infusion is essential to prevent further harm. Increasing the oxytocin infusion would exacerbate the situation, maintaining it would continue the risk, and providing reassurance to the client, although important, does not address the need for immediate action to ensure the safety of the fetus.
2. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?
- A. Avoid prolonged exposure to sunlight.
- B. Take this medication with a meal.
- C. Increase your intake of potassium-rich foods.
- D. Limit your fluid intake to 1 liter per day.
Correct answer: C
Rationale: The correct instruction for a client taking furosemide is to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss, so increasing potassium-rich foods helps prevent hypokalemia. Choice A, avoiding prolonged exposure to sunlight, is not directly related to furosemide use. Choice B, taking the medication with a meal, is not a specific requirement for furosemide administration. Choice D, limiting fluid intake to 1 liter per day, is not the correct advice as furosemide is a diuretic that often requires increased fluid intake to prevent dehydration.
3. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 90/min
- B. Redness and warmth in the calf
- C. Oxygen saturation of 95%
- D. Temperature of 37.3°C (99.1°F)
Correct answer: B
Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.
4. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?
- A. Dry mucous membranes
- B. Polyuria
- C. Epistaxis
- D. Diarrhea
Correct answer: C
Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.
5. What is the primary nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Monitor vital signs
- D. Check oxygen saturation
Correct answer: A
Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.
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