ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Fetal heart rate of 110/min
- B. 1+ pitting edema
- C. Blood pressure 138/80 mm Hg
- D. Urine output of 20 mL/hr
Correct answer: D
Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.
2. How should pain be assessed in a non-verbal patient?
- A. Observe facial expressions
- B. Use the Wong-Baker faces scale
- C. Assess heart rate
- D. Ask the patient to rate their pain
Correct answer: A
Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.
3. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?
- A. Increased urine output.
- B. Hyperactive reflexes.
- C. Hypoactive bowel sounds.
- D. Facial weakness.
Correct answer: D
Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.
4. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?
- A. Drink 2 liters of water per day.
- B. You should restrict your fluid intake to 1 liter per day.
- C. You can drink as much fluid as you want throughout the day.
- D. Limit your fluid intake to 3 liters per day.
Correct answer: B
Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.
5. A nurse is caring for a client who has a new diagnosis of deep-vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Massage the affected leg to relieve discomfort
- B. Place a heating pad on the affected leg
- C. Encourage the client to walk around frequently
- D. Monitor the client's oxygen saturation level
Correct answer: D
Rationale: The correct answer is to monitor the client's oxygen saturation level. Deep-vein thrombosis (DVT) increases the risk of pulmonary embolism, a life-threatening complication. Monitoring oxygen saturation helps in early detection of any signs of compromised respiratory function. Massaging the affected leg can dislodge a blood clot, leading to severe consequences. Applying heat through a heating pad can promote vasodilation and increase the risk of clot dislodgment. While mobility is essential in preventing DVT complications, encouraging excessive walking without proper assessment can potentially dislodge a clot and worsen the condition.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access
ATI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access