ATI RN
ATI RN Exit Exam Test Bank
1. A client with type 1 diabetes mellitus is receiving foot care education from a nurse. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Apply lotion to your feet after bathing.
- D. Trim toenails straight across.
Correct answer: D
Rationale: The correct answer is D: 'Trim toenails straight across.' In clients with diabetes, trimming toenails straight across is important to prevent ingrown toenails, reducing the risk of infections. Soaking feet in warm water daily (choice A) can lead to dry skin and potentially cause skin breakdown in diabetic clients. While wearing cotton socks (choice B) is beneficial for good foot hygiene, it is not as crucial as trimming toenails correctly. Applying lotion to feet after bathing (choice C) is helpful for moisturizing the skin, but the emphasis should be on nail care to prevent complications like ingrown toenails.
2. What is the initial nursing action for a patient presenting with chest pain?
- A. Administer aspirin
- B. Reposition the patient
- C. Provide pain relief
- D. Prepare for surgery
Correct answer: A
Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.
3. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 120/80 mm Hg
- B. Respiratory rate of 16/min
- C. 1+ protein in the urine
- D. Heart rate of 88/min
Correct answer: C
Rationale: The correct answer is C. 1+ protein in the urine is indicative of worsening preeclampsia and should be reported to the provider immediately. Elevated blood pressure (choice A) is expected in preeclampsia, but a reading of 120/80 mm Hg is within the normal range. A respiratory rate of 16/min (choice B) and a heart rate of 88/min (choice D) are also within normal limits and not indicative of worsening preeclampsia.
4. A nurse is reviewing the laboratory results of a client who has hypokalemia. Which of the following findings should the nurse expect?
- A. Serum potassium 5.4 mEq/L
- B. Flat T waves
- C. Elevated ST segments
- D. Bradycardia
Correct answer: B
Rationale: Flat T waves are a characteristic ECG finding in hypokalemia. Hypokalemia causes a decrease in serum potassium levels, leading to altered cardiac conduction. Flat T waves are associated with hypokalemia-induced cardiac dysrhythmias. Elevated ST segments are typically seen in conditions like myocardial infarction, not in hypokalemia. Bradycardia is not a typical manifestation of hypokalemia; instead, tachycardia may occur due to potassium imbalances affecting the heart's electrical activity.
5. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Apply cold compresses to the affected extremity.
- B. Massage the affected extremity every 2 hours.
- C. Elevate the affected extremity above the level of the heart.
- D. Keep the affected extremity dependent when sitting.
Correct answer: C
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.
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