ATI RN
ATI Exit Exam 2024
1. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Blood pressure of 130/85 mm Hg
- C. Coughing up small amounts of sputum
- D. Absent gag reflex
Correct answer: D
Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.
2. The parents of a child with acute postinfectious glomerulonephritis (APIGN) ask how they will know that the condition is improving. How should the nurse respond?
- A. Your child’s urine output will increase, and the urine will become less brown in color.
- B. Your child will rest more comfortably.
- C. Your child’s appetite will decrease.
- D. Your child’s laboratory test values will show increased BUN.
Correct answer: A
Rationale: Improvement in APIGN is indicated by an increase in urine output and a change in urine color from brown (due to hematuria) to a more normal appearance. This reflects a reduction in glomerular inflammation and improved kidney function. Choice B is incorrect because resting more comfortably is not a direct indicator of kidney function improvement. Choice C is incorrect because a decrease in appetite is not typically associated with improvement in APIGN. Choice D is incorrect because an increased BUN value would suggest worsening kidney function rather than improvement.
3. A nurse is caring for an adult client who has prescriptions for multiple medications. Which of the following is an age-related change that increases the risk for adverse effects from these medications?
- A. Rapid gastric emptying
- B. Prolonged medication half-life
- C. Increased medication elimination
- D. Decreased medication sensitivity
Correct answer: B
Rationale: The correct answer is B: Prolonged medication half-life. As clients age, their metabolism tends to slow down, leading to a prolonged half-life of medications in the body. This extended presence of drugs can increase the risk for adverse effects as the substances accumulate. Choice A, rapid gastric emptying, is not an age-related change and actually decreases the time medications spend in the stomach, potentially reducing their effectiveness. Choice C, increased medication elimination, is not an age-related change either; in fact, aging can lead to decreased renal function, affecting drug elimination. Choice D, decreased medication sensitivity, is not an age-related change that directly increases the risk for adverse effects; rather, it may lead to requiring higher doses for effectiveness but does not inherently increase the risk of adverse effects.
4. A client has a new prescription for Digoxin to treat heart failure. Which of the following findings should the nurse monitor as an adverse effect?
- A. Visual disturbances
- B. Dry cough
- C. Confusion
- D. Urinary retention
Correct answer: A
Rationale: Visual disturbances, such as blurred or yellow vision, can be an early sign of digoxin toxicity. Monitoring for visual changes is crucial to detect and prevent potential adverse effects of digoxin. Dry cough, confusion, and urinary retention are not commonly associated adverse effects of digoxin and are not typically monitored in relation to this medication.
5. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?
- A. Check the patient's vital signs every 15 minutes during the transfusion.
- B. Verify the patient's identity with two identifiers before starting the transfusion.
- C. Ensure the blood product is administered within 4 hours of removal from the blood bank.
- D. Ensure the patient has signed the informed consent form.
Correct answer: B
Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.
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