ATI RN
ATI RN Comprehensive Exit Exam
1. A client receiving a blood transfusion develops a fever. What action should the nurse take?
- A. Stop the transfusion immediately.
- B. Administer an antihistamine as prescribed.
- C. Administer a diuretic as prescribed.
- D. Increase the transfusion rate.
Correct answer: A
Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.
2. The nurse is caring for a client on enalapril (Vasotec). What is the most important side effect to monitor?
- A. Cough
- B. Hyperkalemia
- C. Hypotension
- D. Dizziness
Correct answer: A
Rationale: The correct answer is A: Cough. Enalapril is an ACE inhibitor, and cough is a common side effect associated with this class of medication. Monitoring for cough is crucial as it can indicate the development of a potentially serious condition known as angioedema. Hyperkalemia (choice B) is a possible side effect of ACE inhibitors but is not the most important side effect to monitor. Hypotension (choice C) and dizziness (choice D) are also potential side effects of enalapril; however, cough takes precedence due to its association with angioedema, a severe adverse reaction.
3. Which of the following management strategies is not included for a patient taking chemotherapeutic drugs?
- A. Limit exposure of pregnant visitors
- B. Protect client from infection
- C. Allow client to use makeup and wig
- D. Administer IV fluids as ordered
Correct answer: C
Rationale: The correct answer is C. Chemotherapy can lead to hair loss, and while using wigs is common, it is not a primary management strategy. The focus should be on limiting exposure to pregnant visitors to prevent harm to the fetus, protecting the client from infections due to a compromised immune system, and administering IV fluids as ordered to maintain hydration levels. Allowing the client to use makeup and wigs is not a primary concern when managing a patient taking chemotherapeutic drugs.
4. A nurse is providing preventative information to a group of parents with toddlers about choking. Which food item should the nurse recommend for this age group?
- A. Banana slices
- B. Popcorn
- C. Hot dogs
- D. Carrot sticks
Correct answer: A
Rationale: Banana slices are the most suitable food option for toddlers to prevent choking. Toddlers are at a higher risk of choking due to their small airways and developing chewing abilities. Banana slices are soft, easy to chew, and less likely to cause choking compared to other options. Popcorn and hot dogs are common choking hazards for young children due to their shape and texture. While carrot sticks may be a healthy choice, they can also pose a choking risk due to their hardness and shape. Therefore, recommending banana slices to parents of toddlers is the safest choice to prevent choking incidents, making choice 'A' the correct answer. Choices 'B', 'C', and 'D' are incorrect because they can potentially cause choking in toddlers.
5. A client is prescribed furosemide. Which of the following instructions should the nurse include in the teaching?
- A. Take this medication in the morning.
- B. Avoid eating foods high in potassium.
- C. You should take this medication on an empty stomach.
- D. Limit your fluid intake to 1 liter per day.
Correct answer: A
Rationale: The correct instruction for a client prescribed furosemide is to take the medication in the morning. Furosemide, a diuretic, is best taken in the morning to prevent nocturia, which is excessive urination at night. Taking it earlier in the day can help reduce disruptions to sleep patterns. Therefore, advising the client to take furosemide in the morning is crucial for optimal therapeutic effects. Choices B, C, and D are incorrect because furosemide does not require avoiding potassium-rich foods, does not need to be taken on an empty stomach, and does not mandate limiting fluid intake to 1 liter per day.
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