ATI RN
ATI RN Exit Exam
1. What is the best intervention for a patient presenting with respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Reposition the patient
- D. Provide humidified air
Correct answer: A
Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.
2. A client with a new colostomy requires care planning by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Change the ostomy pouch every 4 to 7 days.
- B. Empty the ostomy pouch when it is half full.
- C. Apply a skin barrier around the stoma.
- D. Cleanse the peristomal skin with alcohol.
Correct answer: A
Rationale: The correct answer is to change the ostomy pouch every 4 to 7 days. This practice helps prevent skin irritation and leakage by maintaining a clean and secure seal around the stoma. Option B is incorrect because it is more important to change the pouch regularly rather than emptying it when half full. Option C is incorrect as applying a skin barrier is typically done during the initial application of the pouch, not during regular changes. Option D is incorrect because alcohol can be too harsh for the peristomal skin and can cause irritation.
3. When documenting an incorrect dose of medication administered, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct answer: A
Rationale: The nurse should document the time the medication was given in the client's medical record when an incorrect dose is administered. Recording the time is crucial for establishing the sequence of events accurately. Choices B, C, and D, though important, are not directly relevant to documenting the incident of administering an incorrect dose of medication. The client's response to the medication, the actual dose administered, and the reason for the error may be documented for overall patient care but are not specifically required in the incident report for an incorrect dose.
4. What is the best intervention for a patient with constipation?
- A. Administer a stool softener
- B. Encourage fluid intake
- C. Provide a high-fiber diet
- D. Administer a laxative
Correct answer: B
Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.
5. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Encourage the client to take deep breaths.
- B. Place the client in a high-Fowler's position.
- C. Administer a bronchodilator.
- D. Administer oxygen at 6 L/min via face mask.
Correct answer: B
Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.
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