ATI RN
ATI Comprehensive Exit Exam 2023 With NGN Quizlet
1. A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?
- A. Serous drainage on the dressing
- B. Capillary refill of 2 seconds
- C. Heart rate of 88/min
- D. Pallor of the affected extremity
Correct answer: D
Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.
2. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?
- A. Injecting 10 mL of air into the tube to facilitate drainage.
- B. Applying a water-soluble lubricant to the client's nares.
- C. Coiling extra tubing on the client's bed.
- D. Irrigating the tube with 50 mL of normal saline solution.
Correct answer: D
Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.
3. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?
- A. If only we could have tried again, things might have worked out.
- B. I am so mad that the children and I had to put up with him as long as we did.
- C. Yes, it was a difficult relationship, but I think I have learned from the experience.
- D. I still don't have any appetite and continue to lose weight.
Correct answer: C
Rationale: The nurse should recognize that the client is in the acceptance stage of grief based on the statement 'Yes, it was a difficult relationship, but I think I have learned from the experience.' In this statement, the client is acknowledging the difficulty of the relationship but also expressing personal growth and learning from the experience, indicating acceptance. Choices A, B, and D do not reflect the acceptance stage of grief. Choice A shows a sense of regret and a wish for things to have turned out differently. Choice B demonstrates lingering anger towards the ex-husband. Choice D suggests ongoing physical manifestations of grief like loss of appetite and weight loss, which are more indicative of earlier stages of grief.
4. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?
- A. ‘I will drink at least 3000 mL of water daily.”
- B. . ‘I will shower every day in hot water.”
- C. ‘I will avoid tights belts.”
- D. ‘I will use a humidifier during the winter months.”
Correct answer: . ‘I will shower every day in hot water.”
Rationale:
5. A patient is admitted with chest pain, possible acute coronary syndrome. What should the nurse do first?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Obtain cardiac enzymes
- D. Auscultate heart sounds
Correct answer: A
Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.
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