ATI RN
ATI RN Comprehensive Exit Exam 2023
1. What is the priority nursing intervention for a patient experiencing a myocardial infarction?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Administer morphine
- D. Prepare for surgery
Correct answer: A
Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.
2. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?
- A. Ensure the eye shield is covering the eyes.
- B. Apply lotion to the exposed skin.
- C. Offer glucose water between feedings.
- D. Discontinue breastfeeding during treatment.
Correct answer: A
Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.
3. 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.
4. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
5. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct answer: A
Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.
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