ATI RN
ATI RN Comprehensive Exit Exam
1. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?
- A. Administer oxygen via nasal cannula
- B. Reposition the client onto her left side
- C. Administer an amnioinfusion
- D. Provide reassurance to the client
Correct answer: B
Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.
2. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella roster. Which of the following information should the nurse include?
- A. Children who have varicella are contagious until vesicles are crusted
- B. Children who have varicella should receive the herpes zoster vaccination
- C. Children who have varicella should be placed in droplet precautions
- D. Children who have varicella are contagious 4 days before the first vesicle eruption
Correct answer: A
Rationale: The correct answer is A. Children with varicella are contagious until the vesicles crust over, which is important for preventing transmission. Choice B is incorrect as varicella and herpes zoster are caused by different viruses, so the varicella vaccine is given to prevent varicella, not herpes zoster. Choice C is incorrect because varicella is primarily spread through respiratory secretions, so airborne precautions are recommended, not droplet precautions. Choice D is incorrect as children with varicella are contagious even before the first vesicle eruption, not just 4 days before.
3. A nurse is preparing to administer an IV bolus of 0.9% sodium chloride to a client who is dehydrated. Which of the following actions should the nurse take?
- A. Administer the solution slowly over 24 hours
- B. Assess the client's lung sounds before administration
- C. Change the IV tubing every 12 hours
- D. Flush the IV line with 2 mL of heparin every 4 hours
Correct answer: B
Rationale: The correct action for the nurse to take is to assess the client's lung sounds before administering IV fluids. This is crucial to identify any signs of fluid overload, such as crackles or wheezes. Administering the solution slowly over 24 hours (choice A) is not appropriate for an IV bolus, which is a rapid infusion. Changing the IV tubing every 12 hours (choice C) is a standard practice for preventing infection but is not directly related to administering an IV bolus. Flushing the IV line with heparin every 4 hours (choice D) is a maintenance practice to prevent clot formation in the line, not specifically related to administering an IV bolus.
4. A client is prescribed albuterol. Which of the following instructions should the nurse include?
- A. Take this medication before meals.
- B. You might experience tremors while taking this medication.
- C. Limit your caffeine intake while taking this medication.
- D. Take this medication at bedtime.
Correct answer: B
Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.
5. A client who has a new prescription for warfarin is being taught about the medication's adverse effects by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. ''I should expect mild bruising around my elbows.''
- B. ''I should report a red rash to my provider.''
- C. ''I should stop taking this medication if I develop a cough.''
- D. ''I should expect black, tarry stools.''
Correct answer: D
Rationale: The correct answer is D. Black, tarry stools can indicate gastrointestinal bleeding, a serious adverse effect of warfarin that requires immediate medical attention. Option A is incorrect because while bruising is a common side effect of warfarin, it is not limited to the elbows. Option B is incorrect as a red rash is not a typical adverse effect of warfarin. Option C is also incorrect because developing a cough is not a reason to discontinue warfarin unless advised by a healthcare provider.
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