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. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?
- A. Administer the immunization in the deltoid muscle
- B. Apply a cold compress to the injection site
- C. Apply pressure to the injection site for 5 minutes
- D. Administer a local anesthetic at the injection site
Correct answer: D
Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.
3. 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.
4. A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypoglycemia
- C. Diaphoresis
- D. Tachycardia
Correct answer: A
Rationale: Polyuria is the excessive production of urine and is a common finding in clients with hyperglycemia due to increased glucose levels. High blood sugar levels lead to the body trying to eliminate the excess glucose through urine, resulting in increased urination. Hypoglycemia (choice B) is low blood sugar and is not typically associated with hyperglycemia. Diaphoresis (choice C) is excessive sweating and is not a direct symptom of hyperglycemia. Tachycardia (choice D) is increased heart rate and is not a primary finding in hyperglycemia.
5. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider?
- A. Potassium level 4.2 mEq/L
- B. Apical pulse 58/min
- C. Digoxin level 1 ng/ml
- D. Constipation for 2 days
Correct answer: B
Rationale: The correct answer is B. An apical pulse below 60/min indicates bradycardia, a potential sign of digoxin toxicity. The nurse should report this finding to the provider for further evaluation and possible adjustment of the digoxin dose. Choice A, a potassium level of 4.2 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not indicate toxicity. Choice C, a digoxin level of 1 ng/ml, is within the therapeutic range (0.5-2 ng/ml) and is not suggestive of toxicity. Choice D, constipation for 2 days, is not directly related to digoxin administration and would not require an immediate report to the provider.
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