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?
- A. Cleanse the wound with povidone-iodine.
- B. Apply a hydrocolloid dressing.
- C. Perform debridement as needed.
- D. Keep the wound open to air.
Correct answer: B
Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.
2. 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 to the provider?
- A. Increased hoarseness
- B. Serum calcium level of 8.0 mg/dL
- C. Respiratory rate of 18/min
- D. Urinary output of 60 mL in 2 hours
Correct answer: B
Rationale: The correct answer is B: 'Serum calcium level of 8.0 mg/dL.' A low serum calcium level indicates hypocalcemia, which is a potential complication of thyroidectomy that can lead to life-threatening consequences, such as tetany or laryngospasm. Therefore, it is crucial for the nurse to report this finding promptly to the provider for timely intervention. Choices A, C, and D are important assessments following a thyroidectomy but are not as critical as detecting and addressing hypocalcemia, which can have serious implications for the client's health.
3. 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.
4. How should a healthcare professional care for a patient with a central line to prevent infection?
- A. Change the dressing daily
- B. Monitor for redness
- C. Check the central line site every shift
- D. Flush the line with saline
Correct answer: A
Rationale: Corrected Rationale: Changing the central line dressing daily is crucial in preventing infection at the insertion site. This practice helps maintain a clean and sterile environment around the central line, reducing the risk of pathogens entering the bloodstream. Monitoring for redness (choice B) is important but may not directly prevent infection. Checking the central line site every shift (choice C) is essential for early detection of any issues but does not solely prevent infection. Flushing the line with saline (choice D) is a necessary procedure for maintaining central line patency but does not primarily prevent infection.
5. 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.
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