ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Head compression
- C. Placenta previa
- D. Umbilical cord prolapse
Correct answer: B
Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.
2. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 20/min
- B. Blood pressure of 118/76 mm Hg
- C. Heart rate of 88/min
- D. Oxygen saturation of 94%
Correct answer: C
Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.
3. A healthcare provider is providing discharge instructions to a client who has a new prescription for metformin. Which of the following instructions should the healthcare provider include?
- A. Take this medication with meals.
- B. Avoid consuming alcohol while taking this medication.
- C. Take this medication at bedtime.
- D. Report any muscle pain to your healthcare provider.
Correct answer: B
Rationale: The correct answer is B: 'Avoid consuming alcohol while taking this medication.' Clients taking metformin should avoid alcohol as it increases the risk of lactic acidosis. Choice A is incorrect because metformin is usually taken with meals to reduce gastrointestinal side effects. Choice C is incorrect as metformin is typically taken with meals, not at bedtime. Choice D is incorrect because muscle pain is not a common side effect of metformin.
4. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to breathe deeply and cough every 4 hours.
- B. Provide a diet that is high in carbohydrates and low in protein.
- C. Teach the client pursed-lip breathing technique.
- D. Restrict the client's fluid intake to 1,500 mL per day.
Correct answer: C
Rationale: The correct answer is C: Teach the client pursed-lip breathing technique. Pursed-lip breathing helps clients with COPD improve oxygenation and reduce shortness of breath. Choice A is incorrect because deep breathing and coughing are not recommended every 4 hours for clients with COPD. Choice B is incorrect because a diet high in carbohydrates and low in protein is not specifically indicated for COPD. Choice D is incorrect because fluid restriction is not a standard intervention for COPD unless the client has comorbid conditions that necessitate it.
5. A nurse is caring for a client with Alzheimer's disease who wanders frequently. Which of the following interventions should the nurse include in the plan of care?
- A. Place the client in a well-lit area to reduce wandering.
- B. Ensure that the client wears an identification bracelet at all times.
- C. Keep the client's bed in the lowest position.
- D. Use physical restraints to prevent wandering.
Correct answer: B
Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.
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