ATI RN
ATI RN Comprehensive Exit Exam 2023
1. What is the most appropriate method to assess a patient's level of consciousness?
- A. Use the Glasgow Coma Scale
- B. Assess the patient's orientation
- C. Check pupillary response
- D. Monitor vital signs
Correct answer: A
Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.
2. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 110/70 mm Hg
- B. Heart rate of 88/min
- C. Respiratory rate of 20/min
- D. Temperature of 37.3°C (99.1°F)
Correct answer: D
Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.
3. What is the most appropriate intervention for a patient experiencing hypoglycemia?
- A. Administer glucagon
- B. Provide oral glucose
- C. Administer IV fluids
- D. Monitor blood sugar levels
Correct answer: B
Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.
4. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?
- A. INR 1.8
- B. Hemoglobin 14 g/dL
- C. Platelets 175,000/mm³
- D. Potassium 3.8 mEq/L
Correct answer: A
Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.
5. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?
- A. Perform chest physiotherapy every 4 hours.
- B. Suction the client every 2 hours.
- C. Encourage the client to increase fluid intake.
- D. Administer oxygen via nasal cannula.
Correct answer: C
Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.
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