ATI RN
ATI Comprehensive Exit Exam
1. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
- A. Position the client on their left side.
- B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
- C. Hold the container of the enema solution 61 cm (24 in) above the client.
- D. Advance the enema tubing 15 cm (6 in) into the client's rectum.
Correct answer: C
Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.
2. When taking a child’s blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?
- A. 20%
- B. 40%
- C. 60%
- D. 80%
Correct answer: B
Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.
3. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 16/min.
- B. Blood pressure 118/78 mm Hg.
- C. Urinary output of 30 mL/hr.
- D. Absent deep-tendon reflexes.
Correct answer: D
Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.
4. A healthcare professional is preparing to administer furosemide 80 mg PO daily. The available furosemide oral solution is 10 mg/1 mL. How many mL should the healthcare professional administer?
- A. 8 mL
- B. 10 mL
- C. 6 mL
- D. 12 mL
Correct answer: A
Rationale: To determine the volume to administer, divide the desired dose by the available concentration. In this case, (80 mg / 10 mg/mL) = 8 mL. Therefore, the healthcare professional should administer 8 mL of furosemide oral solution. Choice B (10 mL), C (6 mL), and D (12 mL) are incorrect as they do not accurately calculate the volume needed based on the provided concentration of the solution.
5. What is the combat health support system in the field designed to do?
- A. Provide evacuation to the far rear for treatment and delay return to duty
- B. Project, sustain, and protect the health of the soldier in war and operations other than war
- C. Provide rearward evacuation and reassignment
- D. Provide far rear area care and delayed return to duty
Correct answer: B
Rationale: The correct answer is B. The combat health support system in the field is designed to project, sustain, and protect the health of soldiers in both war and operations other than war. Choice A is incorrect because the system is not primarily focused on providing evacuation to the far rear for treatment, but rather on overall health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is a limited scope compared to the comprehensive support provided by the system. Choice D is incorrect as it narrowly focuses on far rear area care and delayed return to duty, missing the broader aspects of health support and protection.
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