ATI RN
ATI RN Exit Exam 2023
1. A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Use a moisture barrier ointment.
Correct answer: D
Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.
2. A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include?
- A. Cross your legs when sitting to increase circulation.
- B. Bend at the waist when picking up objects.
- C. Avoid crossing your legs when sitting.
- D. Avoid using a raised toilet seat.
Correct answer: C
Rationale: The correct answer is C: 'Avoid crossing your legs when sitting.' After a total hip arthroplasty, it is important for clients to avoid crossing their legs to prevent complications such as dislocation. Crossing the legs can put strain on the new hip joint, increasing the risk of dislocation. Choice A is incorrect as crossing legs can be harmful. Choice B is incorrect as bending at the waist can strain the hip joint, leading to complications. Choice D is incorrect as using a raised toilet seat is recommended after hip surgery to prevent excessive bending at the hip joint.
3. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administration of acetaminophen
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.
4. A patient refused a newly opened fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct answer: A
Rationale: When a patient refuses a newly opened fentanyl patch, the nurse should ask another nurse to witness the disposal of the new patch. This action ensures accountability, proper protocol, and prevents any potential diversion or misuse of the medication. Disposing of the patch in a sharps container (Choice B) is not sufficient as it does not address the need for witness accountability. Sending the patch back to the pharmacy (Choice C) may not be appropriate without proper documentation and witness. Simply documenting the refusal and removing the patch (Choice D) may lack the necessary verification of proper disposal.
5. A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include?
- A. Resume a regular diet immediately.
- B. Remove the adhesive bandage after 3 days.
- C. Begin moderate activity immediately.
- D. Take a tub bath instead of a shower.
Correct answer: B
Rationale: The correct answer is B. The adhesive bandage should be removed 3 days after a laparoscopic cholecystectomy to allow the incision to heal properly. Choice A is incorrect as the client should start with a clear liquid diet and advance to a regular diet as tolerated. Choice C is incorrect because the client should gradually increase activity levels as tolerated. Choice D is incorrect as the client should avoid tub baths and opt for showers to prevent infection and promote healing.
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