ATI RN
ATI RN Exit Exam 2023
1. A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Administer thrombolytics as prescribed.
- B. Massage the affected extremity every 2 hours.
- C. Apply warm compresses to the affected extremity.
- D. Place the client in a supine position with the legs elevated.
Correct answer: C
Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.
2. How should pain be assessed in a non-verbal patient?
- A. Observe facial expressions
- B. Use the Wong-Baker faces scale
- C. Assess heart rate
- D. Ask the patient to rate their pain
Correct answer: A
Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.
3. What is the priority nursing action for a patient with shortness of breath?
- A. Administer oxygen
- B. Reposition the patient
- C. Check oxygen saturation
- D. Elevate the head of the bed
Correct answer: A
Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.
4. A nurse is providing teaching to a client who has mild persistent asthma and has been prescribed montelukast. Which of the following statements should the nurse include in the teaching?
- A. This medication can be used to help you during an acute asthma attack.
- B. This medication helps decrease swelling and mucus production.
- C. This medication should be taken before exercise.
- D. This medication should be taken daily in the evening.
Correct answer: D
Rationale: The correct answer is D. Montelukast should be taken daily in the evening for long-term control of asthma, rather than for immediate relief. Choice A is incorrect because montelukast is not used for acute asthma attacks. Choice B is incorrect as montelukast works by blocking leukotrienes, not by decreasing swelling and mucus production. Choice C is incorrect as montelukast is not specifically taken before exercise.
5. A client with iron deficiency anemia has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take with a glass of milk to prevent stomach upset.
- B. Take with orange juice to enhance absorption.
- C. Take on an empty stomach to increase absorption.
- D. Take with food to reduce gastrointestinal upset.
Correct answer: C
Rationale: The correct instruction is to take ferrous sulfate on an empty stomach to increase absorption. This is because taking it with food or dairy products like milk can reduce its absorption. Orange juice is not recommended as it may interfere with the absorption of iron. Taking ferrous sulfate on an empty stomach may cause gastrointestinal upset, but this can be minimized by gradually increasing the dose.
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