ATI RN
ATI Comprehensive Exit Exam
1. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have my INR checked regularly while taking this medication.
- B. I should avoid eating leafy green vegetables while taking this medication.
- C. I will stop taking this medication if I experience nausea.
- D. I will avoid taking aspirin while taking this medication.
Correct answer: A
Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.
2. A patient with major depressive disorder is being treated with electroconvulsive therapy (ECT). The nurse should monitor the patient for which common side effect?
- A. Memory loss
- B. Hypertension
- C. Weight gain
- D. Hyperglycemia
Correct answer: A
Rationale: Memory loss, especially short-term memory loss, is a common side effect associated with electroconvulsive therapy (ECT). During ECT treatment, the electrical currents passed through the brain can disrupt short-term memory formation. This side effect is usually temporary, but patients should be closely monitored for any changes in memory function during and after the treatment. Choices B, C, and D are incorrect because they are not commonly associated with ECT. Hypertension, weight gain, and hyperglycemia are not typically observed as side effects of ECT.
3. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?
- A. Monitor the client's urinary output.
- B. Assist the client to splint the incision with a pillow when coughing.
- C. Provide the client with a clear liquid diet.
- D. Encourage the client to ambulate in the hallway.
Correct answer: B
Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.
4. A forensic nurse is using the epidemiological triangle to explain factors that contribute to violent behavior. Which of the following factors should the nurse identify as an environmental factor in the epidemiological triangle?
- A. Crowded living conditions
- B. Traumatic brain injury
- C. Alzheimer's disease
- D. Impaired coping abilities
Correct answer: A
Rationale: Crowded living conditions are considered an environmental factor in the epidemiological triangle as they can contribute to the spread of violence. In this context, environmental factors refer to external influences such as social and physical environments. Traumatic brain injury, Alzheimer's disease, and impaired coping abilities are not typically classified as environmental factors in the epidemiological triangle. Traumatic brain injury and Alzheimer's disease are more related to individual health conditions, while impaired coping abilities are more focused on individual psychological factors rather than external environmental influences.
5. In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. When a client has a latex allergy, it is crucial to avoid direct contact with latex-containing products to prevent an allergic reaction. Choosing hypoallergenic latex gloves that are powder-free reduces the risk of the client being exposed to latex allergens. Option A is incorrect because using ethylene oxide for sterilization does not directly address the client's latex allergy. Option C is incorrect because cleansing latex ports with chlorhexidine does not eliminate the risk of latex exposure. Option D is incorrect as it does not specifically address the issue of latex allergy during the procedure.
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