ATI RN
ATI RN Comprehensive Exit Exam 2023
1. A client with a new diagnosis of diabetes mellitus is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will eat a bedtime snack if my blood sugar is below 200 mg/dL.
- B. I will eat more sugar-free candy to help control my blood sugar.
- C. I will check my blood sugar every morning before breakfast.
- D. I will avoid physical activity if my blood sugar is below 100 mg/dL.
Correct answer: C
Rationale: The correct answer is C because checking blood sugar levels every morning before breakfast is a crucial aspect of managing diabetes effectively. This practice helps individuals monitor their blood sugar levels regularly and adjust their treatment plan as needed. Option A is incorrect as consuming a bedtime snack based on blood sugar levels alone may not be an appropriate approach to managing diabetes. Option B is incorrect as relying on more sugar-free candy does not address the overall dietary management of blood sugar levels. Option D is incorrect as avoiding physical activity when blood sugar is below 100 mg/dL can hinder diabetes management, as exercise is generally beneficial for controlling blood sugar levels.
2. What is the most important nursing assessment for a patient with suspected deep vein thrombosis (DVT)?
- A. Check for leg pain
- B. Perform Homan's sign test
- C. Monitor for redness
- D. Assess for warmth and swelling
Correct answer: A
Rationale: The most important nursing assessment for a patient with suspected deep vein thrombosis (DVT) is to check for leg pain. Leg pain is a cardinal symptom of DVT and is often the initial indicator of a blood clot. While assessing for warmth, swelling, and redness are also important in DVT evaluation, leg pain is the most crucial as it can prompt further diagnostic testing and interventions. Performing Homan's sign test is no longer recommended due to its low specificity and potential to dislodge a clot, causing complications. Monitoring for redness is important but may not always be present in DVT cases. Assessing for warmth and swelling is relevant but still secondary to the assessment of leg pain in suspected DVT cases.
3. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.
4. 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.
5. A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?
- A. Take this medication in the evening before bed.
- B. Take this medication on an empty stomach.
- C. Take this medication with a full glass of milk.
- D. Take this medication with an antacid if you experience indigestion.
Correct answer: B
Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.
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