ATI RN
ATI Exit Exam RN
1. A nurse is caring for a client who has deep vein thrombosis. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day.
- B. Avoid massaging the affected extremity to relieve pain.
- C. Do not apply cold packs to the client's affected extremity.
- D. Elevate the client's affected extremity when in bed.
Correct answer: D
Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.
2. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?
- A. Obtain the client's vital signs.
- B. Ensure the client's IV access is patent.
- C. Prime the IV tubing with 0.9% sodium chloride.
- D. Verify the client's identity.
Correct answer: D
Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.
3. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?
- A. Offer the client several choices when scheduling activities.
- B. Confront the client when inappropriate behavior occurs.
- C. Use a calm, reassuring approach when speaking to the client.
- D. Encourage the client to engage in stimulating activities.
Correct answer: C
Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.
4. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct answer: C
Rationale: The correct action the nurse should include for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent constipation, straining, and subsequent bleeding, which is crucial for clients with thrombocytopenia. Encouraging the client to floss daily (Choice A) is important for oral hygiene but not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems to reduce the risk of foodborne illnesses but is not directly related to thrombocytopenia management.
5. A nurse is providing teaching to a client who has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take this medication with orange juice to increase absorption.
- B. Take this medication on an empty stomach.
- C. Take this medication with milk if it causes stomach upset.
- D. Take this medication at bedtime.
Correct answer: A
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take the medication with orange juice to enhance absorption. Orange juice is recommended because of its vitamin C content, which aids in the absorption of iron. Choice B, taking the medication on an empty stomach, is incorrect because ferrous sulfate is better absorbed with food. Choice C, taking the medication with milk if it causes stomach upset, is incorrect as calcium in milk can interfere with iron absorption. Choice D, taking the medication at bedtime, is incorrect as it is usually recommended to take iron supplements between meals or with food to enhance absorption.
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