ATI RN
ATI RN Exit Exam Test Bank
1. While caring for a client receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?
- A. Monitor the client's urine output every 8 hours.
- B. Administer a bolus of 0.9% sodium chloride.
- C. Check the client's blood glucose level every 4 hours.
- D. Flush the TPN line with sterile water before and after administration.
Correct answer: C
Rationale: Checking the client's blood glucose level every 4 hours is essential when managing a client on TPN to monitor for hyperglycemia, a common complication. Monitoring urine output (Choice A) is important but not a priority in this scenario. Administering a bolus of 0.9% sodium chloride (Choice B) is not indicated as it is unrelated to managing TPN. Flushing the TPN line with sterile water (Choice D) is necessary, but it should be done with 0.9% sodium chloride, not water.
2. What is the most important assessment for a patient post-op to monitor for complications?
- A. Monitor vital signs
- B. Monitor the surgical site
- C. Check blood glucose levels
- D. Check for abnormal breath sounds
Correct answer: A
Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.
3. 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.
4. Which medication is commonly prescribed for patients with atrial fibrillation?
- A. Warfarin
- B. Digoxin
- C. Aspirin
- D. Lisinopril
Correct answer: B
Rationale: Digoxin is commonly prescribed to manage atrial fibrillation by controlling heart rate. While Warfarin is used to prevent blood clots, it is not primarily used for controlling heart rate in atrial fibrillation. Aspirin is not the first-line treatment for atrial fibrillation and is generally not recommended for rhythm control. Lisinopril is an ACE inhibitor used to treat high blood pressure and heart failure, but it is not typically prescribed as the primary medication for managing atrial fibrillation.
5. A nurse is caring for a client who is receiving chemotherapy. Which of the following findings should the nurse report to the provider?
- A. Alopecia
- B. Weight gain of 1 kg (2.2 lb) in 24 hours
- C. White blood cell count of 6,000/mm³
- D. Temperature of 37.2°C (99°F)
Correct answer: B
Rationale: The correct answer is B. A weight gain of 1 kg (2.2 lb) in 24 hours is concerning as it indicates fluid retention, which can be a sign of complications in clients receiving chemotherapy. Rapid weight gain can be associated with conditions like fluid overload or electrolyte imbalances, which need prompt medical attention. Choices A, C, and D are not typically immediate concerns related to chemotherapy. Alopecia (choice A) is a common side effect of chemotherapy, a white blood cell count of 6,000/mm³ (choice C) falls within the normal range, and a temperature of 37.2°C (99°F) (choice D) is slightly elevated but not a critical finding in this context.
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