ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is assessing a client who has hypovolemia. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Tachycardia.
- C. Increased blood pressure.
- D. Bounding pulse.
Correct answer: B
Rationale: The correct answer is B: Tachycardia. In hypovolemia, the body responds to decreased fluid volume by increasing the heart rate (tachycardia) to maintain adequate circulation. Bradycardia (Choice A) is not expected in hypovolemia since the heart rate typically increases to compensate for the reduced blood volume. Increased blood pressure (Choice C) is unlikely in hypovolemia as the decreased fluid volume leads to decreased pressure. A bounding pulse (Choice D) is more associated with conditions like hyperthyroidism or fever, not specifically with hypovolemia.
2. During the detoxification stage, it is a priority for the nurse to:
- A. teach skills to recognize and respond to health threatening situations
- B. increase the client’s awareness of unsatisfactory protective behaviors
- C. implement behavior modification
- D. promote homeostasis and minimize the client’s withdrawal symptoms
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
3. Which clinical manifestation should a nurse monitor for when assessing a pediatric client diagnosed with a basilar skull fracture?
- A. Periorbital ecchymosis
- B. Subdural hematoma
- C. Protruding bone
- D. Epidural hematoma
Correct answer: A
Rationale: Periorbital ecchymosis, also known as raccoon eyes, is a classic sign of a basilar skull fracture. It presents as bruising around the eyes due to blood collecting in the tissues. Monitoring for periorbital ecchymosis is crucial in assessing a pediatric client with a basilar skull fracture because it can indicate the presence of this serious injury.
4. During an assessment of a male client suspected of having a disorder of motor function, which finding would suggest a possible upper motor neuron (UMN) lesion?
- A. Hypotonia
- B. Hyperreflexia
- C. Muscle atrophy
- D. Fasciculations
Correct answer: B
Rationale: Hyperreflexia, or exaggerated reflexes, is a common sign of an upper motor neuron (UMN) lesion. An UMN lesion indicates damage to the central nervous system pathways that control movement. Hypotonia (choice A) refers to reduced muscle tone, which is more indicative of lower motor neuron lesions. Muscle atrophy (choice C) suggests long-standing denervation or disuse of muscles. Fasciculations (choice D) are involuntary muscle contractions that can be seen in lower motor neuron lesions, like in amyotrophic lateral sclerosis (ALS), rather than UMN lesions.
5. A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?
- A. I will need to increase my intake of leafy green vegetables.
- B. I will avoid drinking grapefruit juice while taking warfarin.
- C. I will have my INR checked regularly.
- D. I will take my medication at the same time each day.
Correct answer: C
Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.
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