ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
- A. Apply skin preparation to wound edges.
- B. Don sterile gloves.
- C. Normal saline
- D. Determine pain level.
Correct answer: D
Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.
2. A nurse is teaching a client who has a new prescription for alendronate. Which of the following instructions should the nurse include in the teaching?
- A. Take this medication at bedtime.
- B. Take this medication with food.
- C. Remain upright for at least 30 minutes after taking this medication.
- D. Avoid taking this medication with calcium-rich foods.
Correct answer: C
Rationale: The correct answer is C: 'Remain upright for at least 30 minutes after taking this medication.' This instruction is crucial when taking alendronate as it reduces the risk of esophagitis by preventing the medication from irritating the esophagus. Choice A is incorrect because alendronate should be taken in the morning, not at bedtime, to enhance absorption. Choice B is incorrect as alendronate should be taken on an empty stomach, preferably in the morning, with a full glass of water. Choice D is incorrect as there are no specific restrictions on taking alendronate with calcium-rich foods.
3. Which electrolyte imbalance is commonly associated with furosemide?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, commonly causes the loss of potassium in the urine, leading to hypokalemia. This electrolyte imbalance can result in various complications such as cardiac arrhythmias and muscle weakness. Choice B, Hyponatremia, is not typically associated with furosemide use. Choice C, Hyperkalemia, is the opposite of the expected electrolyte imbalance caused by furosemide. Choice D, Hypercalcemia, is not a common side effect of furosemide.
4. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?
- A. Administer nitroglycerin sublingually.
- B. Administer 2L of oxygen via nasal cannula.
- C. Administer aspirin 325 mg orally.
- D. Obtain a 12-lead ECG.
Correct answer: D
Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.
5. What is the best intervention for a patient with respiratory distress?
- A. Administer oxygen
- B. Reposition the patient
- C. Provide bronchodilators
- D. Provide humidified air
Correct answer: A
Rationale: Administering oxygen is the best intervention for a patient with respiratory distress because it helps improve oxygenation levels and alleviates respiratory distress directly. Providing oxygen addresses the primary issue of inadequate oxygen supply, which is crucial in managing respiratory distress. Repositioning the patient, while important for airway clearance, may not address the immediate need for oxygen. Providing bronchodilators and humidified air can be beneficial in certain respiratory conditions, but when a patient is in respiratory distress, ensuring adequate oxygenation through oxygen administration takes precedence.
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