ATI RN
ATI Leadership Proctored Exam 2023
1. 12. A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time will it be most important for the nurse to monitor for symptoms of hypoglycemia?
- A. 10:00 AM
- B. 12:00 PM
- C. 2:00 PM
- D. 4:00 PM
Correct answer: A
Rationale: After receiving aspart (NovoLog) insulin, which has a rapid onset, it is crucial to monitor the patient for symptoms of hypoglycemia during the peak action time. Typically, the peak action of aspart insulin occurs around 2 hours after administration. Therefore, the nurse should be most vigilant for hypoglycemia symptoms at 10:00 AM. Choice B (12:00 PM) is incorrect as it falls after the expected peak action time. Choices C (2:00 PM) and D (4:00 PM) are also incorrect because the peak action time of aspart insulin typically occurs earlier, around 2 hours post-administration.
2. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?
- A. ''OOB with assistance for breakfast''
- B. ''Given 2 mg MSO4 IM for report of pain''
- C. ''Dressing changed qd''
- D. ''Administered 8 units of regular insulin subcutaneously''
Correct answer: ''Administered 8 units of regular insulin subcutaneously''
Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.
3. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Apply a moisture barrier ointment.
Correct answer: D
Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.
4. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Elevate the client's legs while in bed.
- B. Reposition the client every 2 hours.
- C. Maintain bed rest for the first 24 hours postoperatively.
- D. Ambulate the client on the first postoperative day.
Correct answer: D
Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.
5. A client has a new prescription for Spironolactone. Which of the following adverse effects should the nurse instruct the client to monitor?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Hypocalcemia
- D. Hyponatremia
Correct answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia due to its mechanism of action. Hyperkalemia can cause muscle weakness and cardiac dysrhythmias. Therefore, the nurse should educate the client to monitor for signs and symptoms of hyperkalemia while taking Spironolactone.
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