ATI RN
ATI RN Exit Exam
1. How should a healthcare professional manage a patient with fluid overload in heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor intake and output
- D. Administer diuretics
Correct answer: A
Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.
2. A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?
- A. Keep track of calorie intake for food and beverages.
- B. Provide a low-protein, high-carbohydrate diet.
- C. Schedule meals at 6-hour intervals.
- D. Provide a high-protein, high-calorie diet.
Correct answer: D
Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.
3. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
- A. Taking furosemide can cause your potassium levels to be high
- B. Eat foods that are high in sodium
- C. Rise slowly when getting out of bed
- D. Taking furosemide can cause you to be overhydrated
Correct answer: C
Rationale: Furosemide can cause low potassium levels, and clients should be advised to rise slowly to prevent dizziness.
4. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent catheter-associated infections?
- A. Change the catheter every 24 hours
- B. Ensure the drainage bag is positioned above the bladder
- C. Perform routine irrigation of the catheter
- D. Empty the drainage bag every 4 hours
Correct answer: B
Rationale: The correct answer is to ensure the drainage bag is positioned above the bladder. This positioning prevents urine reflux into the bladder, reducing the risk of catheter-associated infections. Changing the catheter too frequently (Choice A) can actually increase the risk of infection by introducing pathogens. Performing routine catheter irrigation (Choice C) is no longer recommended as it can increase the risk of infection by introducing bacteria. Emptying the drainage bag every 4 hours (Choice D) is a standard practice to prevent urinary stasis but is not directly related to preventing catheter-associated infections.
5. What is the initial nursing action for a patient presenting with chest pain?
- A. Administer aspirin
- B. Reposition the patient
- C. Provide pain relief
- D. Prepare for surgery
Correct answer: A
Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.
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