ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?
- A. Administer the medication over 30 minutes.
- B. Monitor the client for a decrease in blood pressure during administration.
- C. Assess the IV site for infiltration during administration.
- D. Premedicate the client with an antiemetic prior to administration.
Correct answer: C
Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.
2. When conducting assessments for malnutrition, which risk factors should the nurse consider? (SATA)
- A. Dental problems
- B. Depression
- C. Ability to read and write
- D. All of the above
Correct answer: D
Rationale: When assessing for malnutrition, nurses should consider multiple risk factors. Dental problems and depression can impact a person's ability to eat and maintain proper nutrition. The ability to read and write may not directly relate to malnutrition risk. The correct answer is 'All of the above' because dental problems and depression are indeed risk factors, along with other factors like the inability to prepare meals and the loss of a spouse.
3. How should a healthcare provider manage a patient with chronic heart failure?
- A. Monitor daily weight
- B. Provide fluid restriction
- C. Administer diuretics
- D. Monitor intake and output
Correct answer: A
Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.
4. Reducing the amount of trans fat in the diet is an effective method of decreasing the risk of CHD. Which food is most likely a source of trans fat?
- A. hot dogs
- B. whole milk
- C. fatty fish
- D. potato chips
Correct answer: D
Rationale: The correct answer is D: potato chips. Potato chips, especially when fried in hydrogenated oils, are a common source of trans fats, which are linked to an increased risk of coronary heart disease (CHD). Hot dogs (choice A) can also contain trans fats if made with processed meats and added fats. Whole milk (choice B) and fatty fish (choice C) do not typically contain trans fats, making them less likely sources compared to potato chips.
5. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?
- A. Blanched stoma
- B. Edematous stoma
- C. Reddish-pink stoma
- D. Brownish-black stoma
Correct answer: A
Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.
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