ATI RN
ATI RN Comprehensive Exit Exam 2023
1. 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.
2. 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.
3. 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.
4. 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?
- A. Calcium level of 9.0 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Respiratory rate of 18/min
- D. Stridor
Correct answer: D
Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.
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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