ATI RN
ATI Exit Exam RN
1. While caring for a client receiving a blood transfusion who reports chills, which action should the nurse take first?
- A. Stop the transfusion.
- B. Administer acetaminophen as prescribed.
- C. Notify the provider.
- D. Check the client's blood pressure.
Correct answer: A
Rationale: The correct action for the nurse to take first when a client reports chills during a blood transfusion is to stop the transfusion. Chills can indicate a transfusion reaction, which is a potentially serious situation. Stopping the transfusion immediately is crucial to prevent further complications. Administering acetaminophen or checking the client's blood pressure can come after ensuring the safety of the client by stopping the transfusion. Notifying the provider is important, but the immediate priority is to stop the transfusion.
2. Which of the following best describes the concept of patient autonomy?
- A. The right of patients to make their own healthcare decisions
- B. The duty to do no harm
- C. The obligation to tell the truth
- D. The responsibility to provide equitable care
Correct answer: A
Rationale: Patient autonomy refers to the right of patients to make their own healthcare decisions based on their values and preferences. It emphasizes the importance of respecting patients' rights to choose their treatment options, even if their decisions may not align with healthcare providers' recommendations. Choice B, the duty to do no harm, refers to the ethical principle of nonmaleficence, which is separate from patient autonomy. Choice C, the obligation to tell the truth, is related to the principle of veracity and does not directly encompass patient autonomy. Choice D, the responsibility to provide equitable care, pertains to the concept of justice in healthcare and is not synonymous with patient autonomy.
3. James' illness can be classified as:
- A. Pneumonia
- B. Very severe illness
- C. Severe pneumonia
- D. No pneumonia
Correct answer: D
Rationale: James' illness can be classified as 'No pneumonia' because there are no general danger signs present, and his breathing rate is normal, indicating the absence of pneumonia.
4. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?
- A. I will need to drain the pouch regularly with a catheter.
- B. I will need to wear a drainage bag for the rest of my life.
- C. The drainage from this type of ostomy will be formed.
- D. I will be able to pass stool from the rectum eventually.
Correct answer: A
Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.
5. A patient reports abdominal cramping during an enema administration. What action should the nurse take?
- A. Increase the flow of the enema
- B. Lower the height of the enema solution container
- C. Stop the enema procedure
- D. Remove the enema tubing
Correct answer: B
Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.
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