ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Obtain a 12-lead ECG.
- C. Administer nitroglycerin sublingually.
- D. Notify the provider.
Correct answer: B
Rationale: The correct answer is to obtain a 12-lead ECG. In a client with a history of angina and reporting chest pain, the priority action is to assess for myocardial infarction, which is best done through an ECG. Administering oxygen, nitroglycerin, or notifying the provider can be important actions but obtaining an ECG takes precedence in evaluating the client's condition.
2. Which lab value is essential for a patient receiving warfarin therapy?
- A. Monitor INR
- B. Monitor sodium levels
- C. Monitor potassium levels
- D. Monitor platelet count
Correct answer: A
Rationale: The correct answer is to monitor the INR (International Normalized Ratio) for a patient receiving warfarin therapy. INR monitoring is crucial to assess the effectiveness of warfarin in preventing blood clots while minimizing the risk of bleeding. Monitoring sodium levels (choice B), potassium levels (choice C), or platelet count (choice D) is not specifically essential for patients on warfarin therapy and does not provide direct information on the drug's anticoagulant effects.
3. Which medication is used to reverse the effects of opioid overdose?
- A. Naloxone
- B. Epinephrine
- C. Atropine
- D. Lidocaine
Correct answer: A
Rationale: Naloxone is the correct answer. Naloxone is specifically used to reverse the effects of opioid overdose by binding to opioid receptors and blocking the effects of opioids. Epinephrine is mainly used to treat severe allergic reactions, Atropine is used for certain types of heart conditions and to reduce salivation or respiratory secretions, and Lidocaine is a local anesthetic used for numbing purposes. Therefore, choices B, C, and D are incorrect in the context of reversing opioid overdose.
4. 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.
5. What is the priority nursing assessment for a patient who has just returned from surgery?
- A. Monitor respiratory rate
- B. Monitor blood pressure
- C. Check the surgical site
- D. Monitor heart rate
Correct answer: A
Rationale: The correct answer is to monitor the patient's respiratory rate. This assessment is essential as it ensures that the patient is breathing adequately post-surgery. Maintaining a patent airway and adequate oxygenation are the top priorities in the immediate postoperative period. Monitoring blood pressure, checking the surgical site, or monitoring heart rate are important assessments but are not the priority immediately upon the patient's return from surgery.
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