ATI RN
ATI RN Exit Exam Test Bank
1. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?
- A. Administer nitroglycerin sublingually.
- B. Administer 2L of oxygen via nasal cannula.
- C. Administer aspirin 325 mg orally.
- D. Obtain a 12-lead ECG.
Correct answer: D
Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.
2. The healthcare provider is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the healthcare provider concern?
- A. Nausea, vomiting, and confusion
- B. Headache, vomiting, and seizures
- C. Sore throat, moist respirations, and cough
- D. Fever, rash, and photophobia
Correct answer: A
Rationale: The symptoms of nausea, vomiting, and confusion are concerning as they are indicative of Reye's syndrome, a rare but serious condition associated with aspirin use in children during viral illnesses. Reye's syndrome can lead to severe complications, including brain and liver damage, hence prompt recognition and management are crucial.
3. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?
- A. Use sterile technique when performing tracheostomy care.
- B. Replace the tracheostomy ties every 24 hours.
- C. Use a sterile brush to clean the inner cannula.
- D. Change the tracheostomy dressing once a week.
Correct answer: C
Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.
4. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?
- A. Sit the client upright
- B. Stop the TPN infusion
- C. Turn the client on their left side
- D. Prepare to add insulin to the TPN infusion
Correct answer: B
Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.
5. Which term describes the conditions that guarantee the occurrence of a disorder?
- A. Necessary causes
- B. Contributory causes
- C. Sufficient causes
- D. Protective factors
Correct answer: C
Rationale: The correct answer is 'Sufficient causes.' Sufficient causes are conditions that alone are enough to guarantee the occurrence of a disorder. Necessary causes refer to factors that must be present for the disorder to occur but are not enough on their own. Contributory causes increase the likelihood of a disorder but are not enough to cause it by themselves. Protective factors are conditions that reduce the likelihood of a disorder occurring.
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