ATI RN
ATI RN Custom Exams Set 2
1. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip prior to initiating the Coumadin
- B. Check the client’s INR prior to beginning Coumadin
- C. Clarify the order with the health care provider as soon as possible
- D. Administer the Coumadin along with the heparin drip as ordered
Correct answer: D
Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.
2. Which type of anemia is associated with chronic kidney disease?
- A. Iron-deficiency anemia
- B. Vitamin B12 deficiency anemia
- C. Aplastic anemia
- D. Erythropoietin deficiency anemia
Correct answer: D
Rationale: The correct answer is D: Erythropoietin deficiency anemia. Chronic kidney disease often leads to anemia due to decreased production of erythropoietin. This hormone, produced by the kidneys, stimulates red blood cell production in the bone marrow. Iron-deficiency anemia (choice A) is more commonly caused by insufficient dietary iron intake or chronic blood loss. Vitamin B12 deficiency anemia (choice B) is usually due to inadequate dietary intake, malabsorption, or pernicious anemia. Aplastic anemia (choice C) is a bone marrow failure disorder characterized by pancytopenia (decreased red blood cells, white blood cells, and platelets) rather than a deficiency in erythropoietin production.
3. A patient with Crohn’s disease is experiencing diarrhea. Which dietary recommendation is appropriate?
- A. High-fiber diet
- B. Low-residue diet
- C. High-fat diet
- D. High-protein diet
Correct answer: B
Rationale: A low-residue diet is appropriate for a patient with Crohn’s disease experiencing diarrhea because it helps reduce bowel movements and manage symptoms. Choice A, a high-fiber diet, can exacerbate diarrhea in Crohn’s disease due to increased bulk and fermentation in the gut. Choice C, a high-fat diet, may be hard to digest and can worsen symptoms. Choice D, a high-protein diet, can be taxing on the digestive system and may not provide the relief needed for diarrhea in Crohn’s disease.
4. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?
- A. Monitor vital signs every two (2) hours until stable
- B. Weigh the client in the same clothing at the same time daily
- C. Administer mouth care every eight (8) hours
- D. A, B, and C
Correct answer: D
Rationale: The correct interventions for a client with fluid volume deficit include monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. Monitoring vital signs helps in early detection of changes, daily weighing can indicate fluid retention or loss, and skin turgor assessment is a reliable indicator of hydration status. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and should not be included in the plan of care for this specific condition.
5. During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct answer: A
Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.