ATI RN
ATI RN Exit Exam Test Bank
1. What is the appropriate nursing action for a patient experiencing an acute allergic reaction?
- A. Administer antihistamines
- B. Administer corticosteroids
- C. Administer oxygen
- D. Administer bronchodilators
Correct answer: A
Rationale: The appropriate nursing action for a patient experiencing an acute allergic reaction is to administer antihistamines. Antihistamines work by blocking the action of histamine, a chemical released during an allergic reaction, and can help relieve symptoms such as itching, swelling, and hives. Corticosteroids are used for severe allergic reactions not responding to antihistamines, as they have anti-inflammatory properties. Oxygen is administered in cases of respiratory distress, while bronchodilators are used for bronchospasms. However, the first-line intervention for an acute allergic reaction is antihistamines.
2. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?
- A. I cannot change my instructions once I have signed them.
- B. My doctor will need to approve my advance directives.
- C. I need a witness to sign my advance directives.
- D. I have the right to refuse treatment.
Correct answer: D
Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement shows an understanding of advance directives because they allow individuals to specify their treatment preferences in advance, including the right to refuse treatment. Choices A, B, and C are incorrect. Choice A is inaccurate as individuals can update or change their advance directives at any time. Choice B is incorrect because while a doctor may discuss advance directives with the client, approval is not required for the directives to be valid. Choice C is also incorrect as a witness is typically required to verify the client's signature, not the other way around.
3. What is the appropriate action when a patient presents with chest pain?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Reposition the patient
- D. Prepare for surgery
Correct answer: A
Rationale: The appropriate action when a patient presents with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in cases of myocardial infarction. Nitroglycerin is commonly used for chest pain related to angina but is not the first-line treatment for all types of chest pain. Repositioning the patient may be necessary for comfort or assessment but is not the immediate priority. Surgery is not typically the first-line intervention for chest pain unless there are specific indications.
4. 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.
5. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?
- A. Have your membranes ruptured?
- B. How far apart are your contractions?
- C. Do you have any active lesions?
- D. Are you positive for beta strep?
Correct answer: C
Rationale: The most appropriate question for the nurse to ask the client in this situation is whether they have any active lesions due to the history of herpes simplex virus. This is crucial to assess the risk of transmission to the newborn during labor. Option A is not the priority in this case as the focus is on the client's history of herpes simplex virus. Option B is important but does not directly relate to the risk of herpes simplex virus transmission. Option D is unrelated to the client's condition and the current situation.
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