ATI RN
ATI RN Comprehensive Exit Exam
1. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?
- A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
- B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
- C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
- D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Correct answer: D
Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.
2. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
- C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct answer: Client will remain free from falls throughout their hospital stay
Rationale:
3. A client had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
- A. Administer enoxaparin 30 mg subcutaneously every 12 hr
- B. Place a wedge or pillow between the client's legs when turning.
- C. Instruct the client to restrict flexion of the hip past 120°.
- D. Encourage the client to perform foot and calf exercises every 2 hr
Correct answer: Instruct the client to restrict flexion of the hip past 120°.
Rationale: Following a total hip arthroplasty, the client should be instructed to restrict hip flexion past 90 degrees to prevent dislocation of the prosthesis. Restricting flexion past 120 degrees is excessive and could lead to complications. Therefore, the nurse should verify this prescription with the provider to ensure the client's safety and proper postoperative care.
4. When assessing a client taking Gemfibrozil, which of the following findings should the nurse identify as an adverse reaction to the medication?
- A. Mental status changes
- B. Tremor
- C. Jaundice
- D. Pneumonia
Correct answer: C
Rationale: Jaundice is an adverse reaction that can occur in clients taking Gemfibrozil due to the potential development of liver impairment. Other symptoms of liver impairment may include anorexia and upper abdominal discomfort. Monitoring for signs of jaundice is crucial to detect and manage adverse effects of the medication promptly. Mental status changes (choice A) are not commonly associated with Gemfibrozil use. Tremor (choice B) is not a typical adverse reaction of Gemfibrozil. Pneumonia (choice D) is not directly linked to Gemfibrozil use but can be a complication in some cases.
5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)
- A. Hypokalemia Flaccid paralysis with respiratory depression
- B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
- C. . Hyponatremia Decreased level of consciousness
- D.
Correct answer: Hyperphosphatemia Paresthesia with sensations of tingling and numbness
Rationale:
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