ATI RN
ATI Comprehensive Exit Exam 2023
1. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Apply a sterile dressing.
- B. Suction the tracheostomy.
- C. Remove the inner cannula.
- D. Clean the stoma with sterile saline.
Correct answer: B
Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.
2. A nurse is assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?
- A. Heart rate 68/min.
- B. Blood pressure 110/70 mm Hg.
- C. Vision changes.
- D. Respiratory rate 18/min.
Correct answer: C
Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.
3. A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
- A. Lipsmacking
- B. Agranulocytosis
- C. Clang association
- D. Alopecia
Correct answer: A
Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.
4. During an in-service about nursing leadership, what information should the nurse include about an effective leader?
- A. Acts as an advocate for the nursing unit.
- B. Prioritizes staff requests over client needs.
- C. Shares personal opinions to influence the group's values.
- D. Provides routine client care and documentation.
Correct answer: A
Rationale: An effective leader advocates for the unit's success and its members. Choice B is incorrect because prioritizing staff requests over client needs does not align with effective leadership, which should focus on client-centered care. Choice C is incorrect as sharing personal opinions to influence the group's values can be biased and may not reflect the best interest of the team. Choice D is incorrect because while providing client care is essential, effective leadership involves more than routine tasks and includes guiding and supporting the team.
5. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?
- A. Client placed in restraints due to aggressive behavior
- B. A new client with a history of 4.5 kg weight loss in the past two months
- C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
- D. Client receiving first ECT treatment today
Correct answer: A
Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access
ATI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access