ATI RN
ATI RN Exit Exam Test Bank
1. What is the most important assessment for a patient post-op to monitor for complications?
- A. Monitor vital signs
- B. Monitor the surgical site
- C. Check blood glucose levels
- D. Check for abnormal breath sounds
Correct answer: A
Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.
2. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.
3. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?
- A. Platelet count 150,000/mm³
- B. aPTT 30 seconds
- C. Sodium 140 mEq/L
- D. Serum creatinine 3.0 mg/dL
Correct answer: D
Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.
4. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?
- A. Palpate another area simultaneously
- B. Ask the child not to laugh or move
- C. Begin with deeper palpation and gradually progress to superficial palpation
- D. Have the child help with palpation by placing his or her hand over the palpating hand
Correct answer: D
Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.
5. A nurse at a local health department is caring for a client who is newly diagnosed with listeriosis. Which of the following actions should the nurse plan to take?
- A. Provide the Centers for Disease Control (CDC) and Prevention with the client's information
- B. Inform the client that they are required to have health department staff directly observe their treatment
- C. Determine whether the condition is reportable under state requirements
- D. Find out whether the condition is endemic in the client's neighborhood
Correct answer: C
Rationale: The correct answer is C: 'Determine whether the condition is reportable under state requirements.' Listeriosis is a reportable disease, meaning healthcare providers are legally required to report cases to public health authorities. By checking the state requirements for reportable diseases, the nurse ensures compliance with public health regulations. Choice A is incorrect because providing the client's information to the CDC is not the immediate action needed. Choice B is incorrect as direct observation of treatment is not a standard procedure for listeriosis. Choice D is also incorrect as determining if the condition is endemic in the client's neighborhood is not the primary concern when managing a diagnosed case of listeriosis.
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