ATI RN
ATI RN Comprehensive Exit Exam
1. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?
- A. Keep the head of the bed elevated to 30 degrees.
- B. Administer IV antibiotics prophylactically.
- C. Change the catheter insertion site every 24 hours.
- D. Monitor the insertion site for redness.
Correct answer: D
Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.
2. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:
- A. Severe and unrelenting, located in the epigastric area and radiating to the back.
- B. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.
- C. Burning and aching, located in the epigastric area and radiating to the umbilicus.
- D. Burning and aching, located in the left lower quadrant and radiating to the hip.
Correct answer: A
Rationale: Acute pancreatitis typically presents with severe, unrelenting pain in the epigastric area that radiates to the back. This pain is due to inflammation and autodigestion of the pancreas.
3. Which intervention is the most appropriate recommendation for relief of teething pain?
- A. Rub gums with aspirin to relieve inflammation
- B. Apply hydrogen peroxide to gums to relieve irritation
- C. Give the infant a frozen teething ring to relieve inflammation
- D. Have the infant chew on a warm teething ring to encourage tooth eruption
Correct answer: C
Rationale: A frozen teething ring is effective for relieving teething pain as the cold helps numb the gums and reduce inflammation, making it a safe and effective method for managing discomfort
4. A school-age child is admitted to the pediatric unit with a vaso-occlusive crisis. Which of these should be included in the nursing plan of care?
- A. Correction of alkalosis
- B. Pain management and administration of heparin
- C. Adequate oxygenation and replacement of factor VIII to correct the sickling
- D. Adequate hydration, oxygenation, and pain management
Correct answer: D
Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia require a comprehensive approach that includes adequate hydration to reduce blood viscosity, oxygenation to prevent further sickling of red blood cells, and aggressive pain management. This approach helps improve tissue perfusion and manage pain effectively. Choices A, B, and C are incorrect. Correction of alkalosis is not a priority in vaso-occlusive crisis management. Administration of heparin is not indicated as it can increase the risk of bleeding in sickle cell patients. Factor VIII replacement is not relevant to sickle cell anemia as it is a treatment for hemophilia, not sickle cell disease.
5. When developing a care plan for a client with generalized anxiety disorder (GAD), which of the following interventions should not be included?
- A. Encourage the client to avoid anxiety-provoking situations.
- B. Teach the client relaxation techniques.
- C. Encourage the client to express their feelings.
- D. Provide a structured daily routine.
Correct answer: A
Rationale: When caring for a client with generalized anxiety disorder (GAD), it is essential to consider therapeutic interventions. Encouraging the client to avoid anxiety-provoking situations is not recommended as it can reinforce their anxiety. Teaching relaxation techniques, encouraging the expression of feelings, and providing a structured daily routine are beneficial strategies in managing generalized anxiety disorder by promoting coping skills and emotional expression while fostering stability and predictability.
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