ATI RN
ATI RN Exit Exam
1. A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 110/70 mm Hg
- B. Temperature of 37.2°C (99°F)
- C. Serosanguineous wound drainage
- D. Bile-colored drainage from the surgical site
Correct answer: D
Rationale: Bile-colored drainage from the surgical site can indicate a bile leak, which is an abnormal finding and should be reported. A blood pressure of 110/70 mm Hg and a temperature of 37.2°C (99°F) are within normal ranges for a postoperative client. Serosanguineous wound drainage, which is a mix of blood and serum, is expected following a surgery like cholecystectomy. Therefore, choices A, B, and C are not findings that require immediate reporting.
2. A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 80/50 mm Hg
- B. Uterine contractions
- C. Urine output 150 mL in 2 hours
- D. Client reports cramping
Correct answer: A
Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.
3. A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct answer: Administer oxygen therapy.
Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.
4. Which individual is most likely to experience the greatest percentage of REM sleep?
- A. Sammy, a preschool child
- B. Jake, a full-term newborn
- C. Sarah, a teenager
- D. Cheryl, a preterm newborn Answer: D Page Ref: 104 Copyright © 2018 Laura E. Berk. All Rights Reserved. 32 Test Bank for Berk, Development Through the Lifespan, 7e Skill Level: Apply Topic: The Newborn Baby’s Capacities Difficulty Level: Moderate
Correct answer: D
Rationale: Preterm newborns, like Cheryl, experience a higher percentage of REM sleep compared to full-term newborns. This is because REM sleep plays a critical role in brain development, and preterm infants have an increased need for brain development due to their early arrival. Therefore, Cheryl, as a preterm newborn, is most likely to experience the greatest percentage of REM sleep among the individuals listed.
5. When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?
- A. Attending to holistic client needs
- B. Ensuring client safety
- C. Avoiding medication errors
- D. Providing client-focused care
Correct answer: B
Rationale: The priority for a nurse working on an inpatient medical-surgical unit is to ensure client safety. This is crucial as errors in hospital care can lead to preventable deaths. While attending to holistic client needs and providing client-focused care are important aspects of nursing, ensuring client safety takes precedence to prevent harm and promote positive patient outcomes.
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