ATI RN
ATI RN Exit Exam Test Bank
1. While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?
- A. Monitor the client's urinary output.
- B. Check the client's blood pressure.
- C. Assess the client for constipation.
- D. Monitor the client's respiratory rate.
Correct answer: D
Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.
2. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?
- A. Bruising at the IV site
- B. Edema at the IV site
- C. Warmth along the IV site
- D. Pallor at the IV site
Correct answer: B
Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.
3. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?
- A. Change the insertion site every 24 hours.
- B. Check the insertion site frequently for signs of infiltration.
- C. Use a macrodropper to facilitate reaching the prescribed flow rate.
- D. Avoid restraining the child to prevent undue emotional stress.
Correct answer: B
Rationale: Frequent monitoring of the IV site for signs of infiltration is crucial to prevent tissue damage, especially in pediatric patients. Changing the site every 24 hours is unnecessary unless complications arise, and using a macrodropper is not specific to pediatric care.
4. In approximately what percentage of cases is the prevalence seen?
- A. Type 1 Diabetes
- B. Type 2 Diabetes
- C. N/A
- D. N/A
Correct answer: A
Rationale: The correct answer is A, Type 1 Diabetes. The prevalence of Type 1 Diabetes is seen in approximately 5% to 10% of cases. This statement highlights a key epidemiological characteristic of Type 1 Diabetes. Choice B, Type 2 Diabetes, is incorrect because the prevalence mentioned does not align with Type 2 Diabetes, which has a much higher prevalence in the general population. Choices C and D are not relevant to the question and can be disregarded.
5. During discharge instructions, a client with a new prescription for Phenytoin should be advised to take which of the following actions?
- A. Brush and floss your teeth regularly.
- B. Avoid drinking grapefruit juice.
- C. Take this medication on an empty stomach.
- D. Increase your intake of calcium-rich foods.
Correct answer: A
Rationale: The correct instruction for a client with a new prescription for Phenytoin is to brush and floss their teeth regularly. Phenytoin is known to cause gingival hyperplasia, a condition that affects the gums. By maintaining good oral hygiene practices such as regular brushing and flossing, the client can help minimize the risk of developing this side effect. Choices B, C, and D are incorrect. Avoiding grapefruit juice is more relevant for medications affected by grapefruit juice metabolism, taking medication on an empty stomach is not specifically indicated for Phenytoin, and increasing calcium-rich foods is not directly related to the side effects or administration of Phenytoin.
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