ATI RN
ATI RN Exit Exam Quizlet
1. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?
- A. Discontinue oxytocin infusion
- B. Increase oxytocin infusion
- C. Decrease oxytocin infusion
- D. Maintain oxytocin infusion
Correct answer: A
Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.
2. A nurse is assessing a client with a history of post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
- A. Dependence on family and friends
- B. Loss of interest in usual activities
- C. Ritualistic behavior
- D. Passive-aggressive behavior
Correct answer: B
Rationale: The correct answer is B: Loss of interest in usual activities. Clients with PTSD often exhibit symptoms such as numbing, which can manifest as a loss of interest in activities they once enjoyed. Choice A, dependence on family and friends, is more indicative of seeking support rather than a direct symptom of PTSD. Choice C, ritualistic behavior, is more commonly associated with conditions like obsessive-compulsive disorder. Choice D, passive-aggressive behavior, is not a typical finding in clients with PTSD.
3. What is the recommended dietary restriction for a patient with chronic kidney disease?
- A. Limit potassium intake
- B. Limit fluid intake
- C. Increase protein intake
- D. Increase carbohydrate intake
Correct answer: B
Rationale: The correct answer is to limit fluid intake for a patient with chronic kidney disease. This restriction helps manage fluid balance to prevent fluid overload. Choices A, C, and D are incorrect. Limiting potassium intake is essential for some patients with kidney disease, but it is not the primary dietary restriction. Increasing protein intake is usually not recommended due to the impaired kidney function in these patients. Increasing carbohydrate intake is also not a standard recommendation for patients with chronic kidney disease.
4. What is the best position for a patient with respiratory distress?
- A. Semi-Fowler's position
- B. Trendelenburg position
- C. Prone position
- D. Supine position
Correct answer: A
Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.
5. What is the most critical lab value to monitor for a patient on heparin therapy?
- A. Monitor aPTT levels
- B. Monitor platelet count
- C. Monitor INR levels
- D. Monitor sodium levels
Correct answer: A
Rationale: The correct answer is to monitor aPTT levels. Activated Partial Thromboplastin Time (aPTT) is crucial for assessing the therapeutic effectiveness of heparin, as it reflects the intrinsic pathway of the coagulation cascade. Monitoring aPTT helps ensure that the patient is within the therapeutic range of heparin, minimizing the risk of bleeding complications. Platelet count (choice B) is important to assess for potential heparin-induced thrombocytopenia but is not the primary lab value to monitor during heparin therapy. INR levels (choice C) are monitored in patients on warfarin therapy, not heparin. Sodium levels (choice D) are not directly related to heparin therapy monitoring.
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