ATI RN
ATI RN Exit Exam Quizlet
1. 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.
2. A nurse is planning care for a client who is 1 day postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include?
- A. Keep the affected leg elevated as needed.
- B. Apply ice packs to the affected knee as prescribed.
- C. Encourage the client to ambulate as soon as possible.
- D. Perform range-of-motion exercises as instructed.
Correct answer: C
Rationale: Encouraging the client to ambulate as soon as possible is essential in preventing complications like deep vein thrombosis post knee arthroplasty. While keeping the affected leg elevated and applying ice packs can be beneficial in certain situations, early ambulation takes precedence in this case. Performing range-of-motion exercises hourly may not be necessary and could potentially cause more harm than good if not done correctly or excessively.
3. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct answer: B
Rationale: The correct answer is B: Tachycardia. In acute alcohol withdrawal, tachycardia is a common finding due to increased sympathetic activity. Bradycardia (Choice A) is less likely in this condition since the sympathetic nervous system is typically overactive. Hyperthermia (Choice C) is not a typical finding in acute alcohol withdrawal. Hypotension (Choice D) is less common compared to tachycardia in this situation.
4. A nurse is assessing a client who has been taking lithium for bipolar disorder. Which of the following findings should the nurse report to the provider?
- A. Tremors
- B. Increased thirst
- C. Weight gain
- D. Diarrhea
Correct answer: A
Rationale: Corrected Rationale: Tremors can indicate lithium toxicity, which should be reported to the provider for further evaluation. Tremors are a significant sign of lithium toxicity and can lead to serious complications if not addressed promptly. Increased thirst, weight gain, and diarrhea are common side effects of lithium but are not typically indicative of toxicity. Therefore, the nurse should prioritize reporting tremors as it requires immediate attention.
5. A nurse is providing discharge teaching to a client who has had a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?
- A. I will avoid sitting in a chair for longer than 30 minutes.
- B. I will avoid crossing my legs when sitting.
- C. I will bend at the hips to pick up items from the floor.
- D. I will avoid using a raised toilet seat.
Correct answer: C
Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.
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