ATI RN
ATI Exit Exam RN
1. A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?
- A. Encourage the client to ambulate twice daily.
- B. Encourage the client to deep breathe and cough every hour.
- C. Encourage the client to use an incentive spirometer every hour.
- D. Instruct the client to avoid coughing to prevent pain.
Correct answer: C
Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.
2. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?
- A. Measuring the abdomen after feedings
- B. Marking the point of measurement with a pen
- C. Measuring the circumference at the symphysis pubis
- D. Using a new tape measure with each assessment to ensure accuracy
Correct answer: B
Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.
3. At what age is binocularity, the ability to fixate on one visual field with both eyes simultaneously, typically achieved?
- A. 1 month
- B. 3 to 4 months
- C. 6 to 8 months
- D. 12 months
Correct answer: B
Rationale: Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is typically achieved by the age of 3 to 4 months. Achieving binocularity at 1 month is too early for most infants as their visual system is still developing. Similarly, 6 to 8 months and 12 months are beyond the normal age range for achieving binocularity, and delayed achievement could indicate potential issues like strabismus, which may lead to visual impairment if not addressed.
4. A client has a new prescription for Enalapril. Which of the following adverse effects should the nurse monitor?
- A. Dry cough
- B. Weight gain
- C. Diarrhea
- D. Nausea
Correct answer: A
Rationale: Corrected Rationale: Enalapril, an ACE inhibitor, commonly causes a persistent dry cough as an adverse effect. The nurse should closely monitor the client for this and instruct them to report it to the healthcare provider if it occurs. Choices B, C, and D are incorrect as weight gain, diarrhea, and nausea are not commonly associated adverse effects of Enalapril.
5. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?
- A. Encourage the patient to perform incentive spirometry.
- B. Assist the patient in ambulating around the unit.
- C. Reposition the patient every 2 hours.
- D. Administer pain medication as prescribed.
Correct answer: A
Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.
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