ATI RN
ATI Exit Exam 2023
1. A client with a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear shoes that are one size larger than your normal size.
- C. Wear cotton socks to keep your feet dry.
- D. Trim your toenails straight across.
Correct answer: D
Rationale: The correct answer is D: "Trim your toenails straight across." This instruction is essential to prevent ingrown toenails in clients with diabetes. Soaking feet in warm water daily (choice A) may increase the risk of skin breakdown and infection. Wearing shoes one size larger than normal (choice B) can lead to friction and cause blisters. While wearing cotton socks (choice C) is generally recommended, the emphasis should be on moisture-wicking materials rather than just cotton.
2. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
- A. Notify the provider
- B. Report the incident to the nurse manager
- C. Monitor vital signs
- D. Fill out an incident report
Correct answer: C
Rationale: The correct first action for the nurse to take after realizing that the wrong medication has been administered to a client is to monitor vital signs. Monitoring vital signs is crucial as it allows the nurse to promptly assess for any immediate adverse effects that may result from the wrong medication. This immediate assessment is essential for ensuring the client's safety and well-being. Notifying the provider (choice A) and reporting the incident to the nurse manager (choice B) are important steps to take, but they should come after ensuring the client's immediate safety. Filling out an incident report (choice D) is also necessary but should be done after addressing the client's immediate needs.
3. A nurse is assessing a client who is in active labor. The FHR baseline has been 100/min for the past 15 minutes. What condition should the nurse suspect?
- A. Maternal fever.
- B. Fetal anemia.
- C. Maternal hypoglycemia.
- D. Chorioamnionitis.
Correct answer: C
Rationale: In this scenario, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.
4. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?
- A. Diaphoresis
- B. Hypotension
- C. Urinary retention
- D. Tachycardia
Correct answer: C
Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.
5. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?
- A. Perform an ECG every 12 hours
- B. Place the client in a supine position while resting
- C. Draw a troponin level every 4 hours
- D. Obtain a cardiac rehabilitation consultation
Correct answer: D
Rationale: After an acute myocardial infarction, it is important to involve the client in cardiac rehabilitation to help them recover and manage their condition effectively. Performing an ECG every 12 hours is not necessary unless there are specific indications for it. Placing the client in a supine position may not be ideal as it can increase venous return, potentially worsening cardiac workload. Drawing troponin levels every 4 hours is excessive and not recommended as troponin levels usually peak within 24-48 hours post-MI and then gradually decline.
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