ATI RN
ATI RN Exit Exam Quizlet
1. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?
- A. Glasgow Coma Scale score of 15
- B. Blood drainage on the initial dressing measuring 3 cm
- C. Report of dry mouth
- D. Urinary output greater than fluid intake
Correct answer: D
Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.
2. What is the most important nursing action for a patient experiencing a deep vein thrombosis (DVT)?
- A. Administer anticoagulants
- B. Encourage ambulation
- C. Apply compression stockings
- D. Monitor oxygen saturation
Correct answer: A
Rationale: Administering anticoagulants is the most crucial nursing action for a patient experiencing a deep vein thrombosis (DVT). Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Encouraging ambulation, applying compression stockings, and monitoring oxygen saturation are important interventions in managing DVT, but administering anticoagulants takes priority as it directly targets the clotting process and prevents clot progression.
3. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?
- A. Offer the client several choices when scheduling activities.
- B. Confront the client when inappropriate behavior occurs.
- C. Use a calm, reassuring approach when speaking to the client.
- D. Encourage the client to engage in stimulating activities.
Correct answer: C
Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.
4. What is the best initial action when a patient presents with confusion?
- A. Administer IV fluids
- B. Perform a neurological assessment
- C. Administer electrolytes
- D. Prepare for a CT scan
Correct answer: B
Rationale: When a patient presents with confusion, the best initial action is to perform a neurological assessment. This assessment helps in identifying potential causes of confusion such as neurological issues, infections, metabolic abnormalities, or medication side effects. Administering IV fluids (Choice A) may be necessary based on assessment findings, but it is not the first step. Administering electrolytes (Choice C) would also depend on the assessment results. Preparing for a CT scan (Choice D) may be indicated later in the diagnostic process but is not the initial action when a patient presents with confusion.
5. A client is postoperative following a total knee arthroplasty. Which of the following instructions should the nurse include in the discharge teaching?
- A. Cross your legs when sitting to prevent discomfort.
- B. Perform range-of-motion exercises every 4 hours.
- C. Wear compression stockings daily.
- D. Apply heat to the incision site daily.
Correct answer: C
Rationale: The correct answer is C: 'Wear compression stockings daily.' Wearing compression stockings is essential after knee surgery to prevent venous stasis and reduce the risk of blood clots. Choice A is incorrect as crossing legs when sitting can increase the risk of blood clots. Choice B is incorrect because performing range-of-motion exercises every 4 hours may not be suitable for all clients post total knee arthroplasty. Choice D is incorrect as applying heat to the incision site can increase the risk of infection.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99