ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?
- A. Insert a lubricated gloved finger and advance along the rectal wall
- B. Apply lubricant and stimulate peristalsis
- C. Apply pressure to the abdomen to assist with removal
- D. Increase fluid intake before the procedure
Correct answer: A
Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.
2. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client’s BP is 110/70
- B. The client’s potassium level is 3.4 mEq/L
- C. The client has a barky cough
- D. The client’s apical pulse is 56
Correct answer: D
Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering a beta blocker as the blood pressure is within normal range. Choice B is not directly related to the administration of a beta blocker. Choice C may indicate a potential adverse effect of another medication, but it does not specifically warrant questioning the administration of the beta blocker.
3. Examination of the abdomen is performed correctly by the nurse in which order?
- A. Inspection, palpation, percussion, and auscultation
- B. Inspection, percussion, auscultation, and palpation
- C. Palpation, percussion, auscultation, and inspection
- D. Inspection, auscultation, percussion, and palpation
Correct answer: D
Rationale: The correct order for abdominal examination is inspection, auscult
4. A client has been taking Phenylephrine nasal drops for the past 10 days for Sinusitis. The nurse should assess the client for which of the following adverse effects of this medication?
- A. Sedation
- B. Nasal congestion
- C. Productive cough
- D. Constipation
Correct answer: B
Rationale: The correct answer is B: Nasal congestion. After more than 5 days of use, nasal sympathomimetic medications like phenylephrine can lead to rebound nasal congestion. This occurs due to prolonged vasoconstriction of nasal blood vessels, causing worsening nasal congestion. Sedation (choice A) is not a common adverse effect of phenylephrine nasal drops. Productive cough (choice C) and constipation (choice D) are also not typical adverse effects associated with this medication.
5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct answer: A
Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.
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