ATI RN
ATI Exit Exam
1. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?
- A. Hemoglobin
- B. aPTT
- C. INR
- D. Platelet count
Correct answer: B
Rationale: The correct answer is B: aPTT. The activated partial thromboplastin time (aPTT) is monitored to assess the therapeutic effect of heparin and to adjust the infusion rate if needed. Monitoring hemoglobin levels (choice A) is important for assessing anemia but is not specific to heparin therapy. INR (choice C) is used to monitor the effects of warfarin, not heparin. Platelet count (choice D) is important to monitor for heparin-induced thrombocytopenia, but aPTT is the primary laboratory value used to monitor heparin therapy.
2. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?
- A. Verify the client's blood type with the provider's prescription
- B. Ensure the client's consent for the transfusion is on file
- C. Administer a diuretic prior to starting the transfusion
- D. Check the client's temperature prior to the transfusion
Correct answer: A
Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.
3. What health instruction will enhance regulation of a colostomy (defecation) of clients?
- A. Irrigate after lunch everyday
- B. Eat fruits and vegetables in all three meals
- C. Eat balanced meals at regular intervals
- D. Restrict exercise to walking only
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
4. In children with Type 1 diabetes, what is a common early sign of hypoglycemia?
- A. Irritability
- B. Rapid heartbeat
- C. Confusion
- D. Sweating
Correct answer: D
Rationale: Sweating is indeed one of the earliest signs of hypoglycemia in children with Type 1 diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, which can lead to sweating. While irritability, rapid heartbeat, and confusion can also be seen in hypoglycemia, sweating is particularly common as a quick indicator of low blood sugar levels in children with Type 1 diabetes.
5. Which goal is most appropriate for a patient who has had a total hip replacement?
- A. The nurse will assist the patient in ambulating in the hall 2 times a day.
- B. The patient will walk 100 feet using a walker by the time of discharge.
- C. The patient will ambulate briskly on the treadmill by the time of discharge.
- D. The patient will ambulate independently by the time of discharge.
Correct answer: B
Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.
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