ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is caring for a client who is 36 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 92/min
- B. Serosanguineous wound drainage
- C. Yellow wound drainage
- D. Blood pressure of 118/76 mm Hg
Correct answer: C
Rationale: Yellow wound drainage can indicate infection, especially 36 hours postoperative, and should be reported to the provider promptly. Serosanguineous drainage is a normal finding in the early stages of wound healing, and a heart rate of 92/min and a blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client. Therefore, the nurse should prioritize reporting the yellow wound drainage as it may require immediate intervention.
2. A client requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I had a bowel movement, but I was able to save the urine.''
- B. ''I have a specimen in the bathroom from about 30 minutes ago.''
- C. ''I drink a lot, so I will fill up the bottle and complete the test quickly.''
- D. ''I flushed what I urinated at 7:00 a.m. and have saved all urine since.''
Correct answer: C
Rationale: Option C demonstrates an understanding of the need to collect urine over 24 hours. The client's statement shows awareness that increased fluid intake will help in filling up the collection bottle quickly, which is essential for an accurate test result. This choice reflects the correct understanding of the teaching. Options A, B, and D do not reflect the necessary comprehension for a 24-hr urine collection process. Option A involves a bowel movement, which is not relevant to a urine collection. Option B only mentions a specimen from 30 minutes ago, not over a 24-hour period. Option D indicates flushing urine, which contradicts the idea of saving all urine for the test.
3. What is the first intervention when a patient has difficulty breathing post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Check oxygen saturation
- D. Elevate the head of the bed
Correct answer: A
Rationale: Administering oxygen is the initial intervention for a patient experiencing breathing difficulties post-surgery. Providing oxygen helps improve oxygenation and alleviate respiratory distress. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in addressing hypoxia and respiratory compromise.
4. A nurse is caring for a client who has a body mass index (BMI) of 30. Four weeks after nutritional counseling, which of the following evaluation findings indicates the plan of care was followed?
- A. BMI of 25
- B. Weight gain of 1.8 kg
- C. BMI of 33
- D. Weight loss of 2.7 kg
Correct answer: D
Rationale: A weight loss of 2.7 kg in four weeks indicates effective adherence to a nutritional plan aimed at reducing body mass index (BMI), moving towards a healthier weight. Choices A, B, and C are incorrect because a decrease in weight, as shown in choice D, is the desired outcome when managing a client with a BMI of 30 to reach a healthier range.
5. Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?
- A. Abdominal CT scan
- B. Abdominal x-ray
- C. Colonoscopy
- D. Fecal occult blood test
Correct answer: D
Rationale: A fecal occult blood test should be performed annually for individuals over age 50 to screen for colon cancer.
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