ATI RN
ATI RN Comprehensive Exit Exam 2023
1. What is the primary nursing intervention for a patient experiencing hypoglycemia?
- A. Administer IV fluids
- B. Check blood sugar levels
- C. Provide oral glucose
- D. Recheck blood sugar levels in 15 minutes
Correct answer: D
Rationale: The correct answer is to recheck blood sugar levels in 15 minutes. This intervention is crucial to ensure that the hypoglycemia has been effectively corrected after the initial treatment. Administering IV fluids may be necessary in cases of severe dehydration but is not the primary intervention for hypoglycemia. Checking blood sugar levels is important, but the primary intervention should focus on treating the low blood sugar levels first, which is done by providing oral glucose. However, the most critical step after providing initial treatment is to recheck blood sugar levels to confirm that they have improved to safe levels.
2. Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?
- A. Hepatotoxicity
- B. Wernicke's aphasia
- C. Suicidal ideations
- D. Diarrhea
Correct answer: A
Rationale: The correct answer is A: Hepatotoxicity. Disulfiram is known to cause hepatotoxicity as a severe adverse effect. This occurs due to the inhibition of aldehyde dehydrogenase, leading to the accumulation of acetaldehyde when alcohol is consumed. Wernicke's aphasia (Choice B) is a language disorder unrelated to disulfiram therapy. Suicidal ideations (Choice C) may be associated with certain medications, but it is not a common adverse effect of disulfiram. Diarrhea (Choice D) is not a typical adverse effect of disulfiram.
3. A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?
- A. Monitor the patient's pain level.
- B. Assess the patient's vital signs.
- C. Assess the surgical incision site.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.
4. Which of the following wounds is most likely to heal by secondary intention?
- A. A finger laceration received while cutting onions
- B. A stage IV pressure ulcer that developed in a nursing home
- C. A needlestick injury received while administering parenteral medication
- D. An incision from an open appendectomy
Correct answer: B
Rationale: A stage IV pressure ulcer is a deep wound involving tissue loss that typically heals by secondary intention. This process involves the wound healing from the bottom up with granulation tissue and often results in significant scarring. Choice A, a finger laceration, would generally heal by primary intention due to its clean edges and minimal tissue loss. Choice C, a needlestick injury, is likely to be sutured and heal by primary intention since it is a small, clean wound. Choice D, an incision from an open appendectomy, is usually closed with sutures and heals by primary intention as well.
5. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?
- A. Monitor the patient's vital signs.
- B. Check the patient's weight daily.
- C. Measure the patient's intake and output.
- D. Monitor the patient's urine color.
Correct answer: B
Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.
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