ATI RN
ATI RN Comprehensive Exit Exam 2023
1. A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself every morning.
- B. I should drink 2 liters of water each day.
- C. I should avoid all physical activity.
- D. I should take an extra dose of diuretic if I gain 2 pounds in a day.
Correct answer: A
Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.
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 providing discharge instructions to a client who is postoperative following a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat.
- C. I will sleep on my affected side.
- D. I will perform leg exercises every hour while awake.
Correct answer: C
Rationale: The correct answer is C. Sleeping on the affected side could increase the risk of dislocation following a hip arthroplasty. It is essential for the client to avoid sleeping on the surgical side to prevent complications. Choices A, B, and D are correct statements that promote proper postoperative care and reduce the risk of complications. Avoiding crossing legs when sitting, using a raised toilet seat for proper positioning, and performing leg exercises regularly help in the recovery process and prevent complications.
4. What is the primary purpose of administering an antiemetic?
- A. To reduce nausea and vomiting
- B. To increase appetite
- C. To treat nausea caused by chemotherapy
- D. To treat allergic reactions
Correct answer: A
Rationale: The correct answer is A: 'To reduce nausea and vomiting.' Antiemetics are medications used to prevent or alleviate nausea and vomiting. While they may indirectly help with appetite by reducing the unpleasant symptoms that can lead to decreased food intake, their primary purpose is not to increase appetite (Choice B). Choice C, 'To treat nausea caused by chemotherapy,' is partly correct as antiemetics are commonly used to manage chemotherapy-induced nausea, but this is not their exclusive purpose. Choice D, 'To treat allergic reactions,' is incorrect as antiemetics are not primarily used for treating allergic reactions.
5. 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.
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