ATI RN
ATI Exit Exam 2024
1. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?
- A. Acrocyanosis
- B. Vernix caseosa
- C. A respiratory rate of 50/min
- D. Heart rate of 160/min
Correct answer: D
Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.
2. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?
- A. Bone marrow transplant
- B. Splenectomy
- C. Frequent blood transfusions
- D. Liver biopsy
Correct answer: B
Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis as it helps prevent hemolysis and improve anemia. Removing the spleen reduces the destruction of the abnormal red blood cells. Choice A, Bone marrow transplant, is not a standard treatment for hereditary spherocytosis. Choice C, Frequent blood transfusions, may be used to manage anemia in some cases but is not the primary treatment for hereditary spherocytosis. Choice D, Liver biopsy, is not a treatment for hereditary spherocytosis; it is a procedure used to diagnose liver conditions, not related to this hematologic disorder.
3. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the healthcare professional take first?
- A. Check the residual volume before administering the feeding
- B. Elevate the head of the bed to 30 degrees
- C. Flush the tube with 10 mL of sterile water
- D. Verify the client's tube placement
Correct answer: D
Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.
4. For a rectal examination, the patient can be directed to assume which of the following positions?
- A. Genupectoral
- B. Sims
- C. Horizontal recumbent
- D. All of the above
Correct answer: B
Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.
5. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?
- A. I know you say you hear voices, but I cannot hear them.
- B. Stop listening to the voices, they are NOT real.
- C. You say you hear voices, what are they telling you?
- D. Please tell the voices to leave you alone for now.
Correct answer: C
Rationale: Asking about the content of the voices helps understand the patient's experience and assess risk.
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