ATI RN
ATI RN Exit Exam
1. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Massage the affected extremity to promote circulation.
- B. Elevate the affected extremity.
- C. Apply cold packs to the affected extremity.
- D. Perform range-of-motion exercises on the affected extremity.
Correct answer: C
Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.
2. What is the priority nursing intervention for a patient with hyperkalemia?
- A. Administer calcium gluconate
- B. Administer insulin
- C. Administer sodium bicarbonate
- D. Administer a diuretic
Correct answer: A
Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.
3. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes mellitus. Which of the following client statements indicates a need for further teaching?
- A. I will check my blood glucose level once a week.
- B. I will eat a snack if my blood glucose level is above 200 mg/dL.
- C. I will take my insulin as prescribed, even when I am feeling well.
- D. I will avoid physical activity if my blood glucose level is below 100 mg/dL.
Correct answer: B
Rationale: The correct answer is B. Clients should eat a snack when their blood glucose level is low, typically below 70-100 mg/dL, not when it is high. Eating a snack when the blood glucose level is above 200 mg/dL can exacerbate hyperglycemia. Choice A is correct as checking blood glucose levels regularly is important in managing diabetes. Choice C is also correct as adherence to prescribed insulin therapy is crucial. Choice D is incorrect as physical activity can help lower blood glucose levels, especially when they are above the target range.
4. What is the correct method to teach a patient about self-administration of insulin?
- A. Inject into the upper arm
- B. Rotate injection sites
- C. Use a 45-degree angle for injection
- D. Use a 90-degree angle for injection
Correct answer: D
Rationale: The correct method to teach a patient about self-administration of insulin is to use a 90-degree angle for injection. This angle ensures proper subcutaneous administration of insulin, which is essential for effective absorption. Injecting into the upper arm (Choice A) is not recommended for insulin administration. While rotating injection sites (Choice B) is important to prevent lipodystrophy, the angle of injection is crucial for proper insulin delivery. Using a 45-degree angle (Choice C) is more suitable for intramuscular injections, not for subcutaneous insulin injections.
5. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of water every 4 hours.
- B. Position the client on the left side during feedings.
- C. Elevate the head of the bed to 45 degrees during feedings.
- D. Check gastric residual every 2 hours.
Correct answer: C
Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.
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