ATI RN
ATI RN Comprehensive Exit Exam
1. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?
- A. Low back pain
- B. Tachycardia
- C. Flushed skin
- D. Headache
Correct answer: B
Rationale: The correct answer is B: Tachycardia. Tachycardia can indicate a hemolytic transfusion reaction, a severe and life-threatening complication of blood transfusion. The nurse should report tachycardia immediately to prevent further complications. Low back pain, flushed skin, and headache are also important to monitor during a blood transfusion, but they are not as indicative of a severe transfusion reaction as tachycardia.
2. When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will stop taking my medication once my blood pressure is within normal range.
- D. I will sit quietly for 5 minutes before measuring my blood pressure.
Correct answer: D
Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.
3. A nurse is providing teaching to a client who has osteoporosis. Which of the following instructions should the nurse include?
- A. Take a calcium supplement once daily.
- B. Walk for 30 minutes three times per week.
- C. Avoid weight-bearing exercises.
- D. Increase intake of vitamin D.
Correct answer: B
Rationale: The correct answer is B. Walking regularly is beneficial for clients with osteoporosis as it helps maintain bone density and prevent fractures. Choice A is not the most appropriate because clients with osteoporosis often require more than just calcium supplements. Choice C is incorrect as weight-bearing exercises actually help strengthen bones. Choice D is important, but walking regularly has a more direct impact on bone health in clients with osteoporosis.
4. 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.
5. A nurse is assessing a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serosanguineous drainage on the dressing
- B. Heart rate of 88/min
- C. Urine output of 30 mL/hr
- D. Blood pressure of 110/70 mm Hg
Correct answer: C
Rationale: The correct answer is C because a urine output of 30 mL/hr indicates oliguria, which can be a sign of dehydration or kidney impairment postoperatively. This finding should be reported to the provider for further evaluation. Choices A, B, and D are within normal parameters for a client who is 2 days postoperative following abdominal surgery and do not raise immediate concerns. Serosanguineous drainage on the dressing is an expected finding in the early postoperative period, a heart rate of 88/min is within the normal range, and a blood pressure of 110/70 mm Hg is also within normal limits.
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