ATI RN
ATI Exit Exam
1. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Use a 21-gauge needle for injection.
- B. Inject the medication into the client's deltoid muscle.
- C. Administer the medication within 5 cm (2 in) of the umbilicus.
- D. Massage the injection site after administration.
Correct answer: C
Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.
2. When preparing education materials for a client, what technique should be used to make the information accessible?
- A. Emphasize important information using bold lettering.
- B. Use a 7th-grade reading level.
- C. Avoid using cartoons in the material.
- D. Use words with three or four syllables.
Correct answer: B
Rationale: The correct answer is to use a 7th-grade reading level. This technique ensures that the information provided is accessible and easily understandable for most clients. Using simple language helps to avoid confusion and ensures that the message is conveyed clearly. Emphasizing important information using bold lettering (Choice A) can be helpful but may not improve overall accessibility. Avoiding cartoons in the material (Choice C) is not directly related to making information accessible. Using words with three or four syllables (Choice D) can complicate the material and hinder understanding, making it less accessible.
3. A nurse is caring for a client who has a new diagnosis of rheumatoid arthritis. Which of the following laboratory findings should the nurse expect?
- A. Increased WBC count.
- B. Decreased hemoglobin.
- C. Decreased platelet count.
- D. Positive rheumatoid factor.
Correct answer: D
Rationale: The correct answer is D: Positive rheumatoid factor. A positive rheumatoid factor is a common laboratory finding in clients with rheumatoid arthritis, indicating an autoimmune response. Option A, increased WBC count, is not typically associated with rheumatoid arthritis. Option B, decreased hemoglobin, and option C, decreased platelet count, are not specific laboratory findings for rheumatoid arthritis.
4. A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?
- A. aPTT of 38 seconds
- B. Hemoglobin of 15 g/dL
- C. Platelet count of 80,000/mm3
- D. INR of 1.0
Correct answer: C
Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.
5. A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid using aspirin for pain.
- B. I will consume dairy products to increase my calcium intake.
- C. I will drink 1.5 to 2 liters of fluid each day.
- D. I will need to limit my intake of fiber.
Correct answer: A
Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.
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