ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 120/80 mm Hg
- B. Respiratory rate of 16/min
- C. 1+ protein in the urine
- D. Heart rate of 88/min
Correct answer: C
Rationale: The correct answer is C. 1+ protein in the urine is indicative of worsening preeclampsia and should be reported to the provider immediately. Elevated blood pressure (choice A) is expected in preeclampsia, but a reading of 120/80 mm Hg is within the normal range. A respiratory rate of 16/min (choice B) and a heart rate of 88/min (choice D) are also within normal limits and not indicative of worsening preeclampsia.
2. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?
- A. Flush the tube with 10 mL of water after feeding
- B. Flush the tube with 30 mL of water before feeding
- C. Place the client in a left lateral position
- D. Place the feeding bag 61 cm (24 in) above the client's abdomen
Correct answer: B
Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.
3. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?
- A. Blood pressure of 98/58 mm Hg
- B. Urine output of 50 mL/hr
- C. Serum potassium level of 3.2 mEq/L
- D. Weight loss of 0.5 kg (1.1 lb) in 24 hours
Correct answer: C
Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.
4. A nurse is assessing a client who is 1 day postoperative following hip replacement surgery. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Serosanguineous drainage on the surgical dressing
- C. Blood pressure of 118/76 mm Hg
- D. Urine output of 40 mL/hr
Correct answer: D
Rationale: The correct answer is D: Urine output of 40 mL/hr. A low urine output may indicate kidney complications, such as acute kidney injury, which is a critical finding postoperatively. The nurse should report this immediately to the provider for further evaluation and management. Choices A, B, and C are within normal limits for a client who is 1 day postoperative following hip replacement surgery and do not indicate immediate concerns that require reporting to the provider.
5. A client is 2 hours postoperative following a cholecystectomy. Which of the following interventions should the nurse implement?
- A. Place the client in a supine position
- B. Administer morphine for pain relief
- C. Apply a warm compress to the incision site
- D. Place a pillow under the client's knees
Correct answer: B
Rationale: Administering morphine for pain relief is crucial for postoperative clients following a cholecystectomy to manage pain effectively. Placing the client in a supine position may not be ideal as it can cause discomfort and hinder breathing. Applying a warm compress to the incision site can increase the risk of infection. Placing a pillow under the client's knees is not a priority intervention compared to pain management.
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