ATI RN
ATI Comprehensive Exit Exam 2023
1. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?
- A. Obtain a baseline ECG
- B. Obtain a blood specimen for ABG analysis
- C. Insert an 18-gauge IV catheter
- D. Administer 100% humidified oxygen
Correct answer: D
Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.
2. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?
- A. Retake the temperature in 15 minutes after giving the Tylenol.
- B. Place a warm blanket on the child so chilling does not occur.
- C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
- D. Use cold compresses instead of Tylenol to control the fever.
Correct answer: C
Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.
3. Located in the middle of the brain, what organ is responsible for satiety and hunger?
- A. Medulla Oblongata
- B. Pituitary Gland
- C. Hypothalamus
- D. Parathyroid
Correct answer: C
Rationale: The hypothalamus, located in the middle of the brain, plays a crucial role in regulating hunger and satiety. It contains specific regions that control appetite and feeding behavior. The Medulla Oblongata (Choice A) is responsible for regulating vital functions like heartbeat and breathing, not hunger. The Pituitary Gland (Choice B) is an endocrine gland that secretes hormones but is not primarily involved in hunger regulation. The Parathyroid (Choice D) is responsible for regulating calcium levels in the body and not related to hunger or satiety.
4. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?
- A. After stroking the lateral area of the foot, the client's toes contract and draw together
- B. After hip flexion, the client is unable to extend their leg completely without pain
- C. The client's voluntary movement is not coordinated
- D. The client reports pain and stiffness when flexing their neck
Correct answer: B
Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.
5. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Mixed acidbase disorder
Correct answer: Mixed acidbase disorder
Rationale:
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