ATI RN
ATI Exit Exam 2023
1. 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.
2. A client with cancer is about to receive low-dose brachytherapy via a vaginal implant. What intervention should be included in the care plan?
- A. Remove vaginal packing.
- B. Insert an indwelling urinary catheter.
- C. Ambulate the client four times daily.
- D. Keep the client NPO until therapy is complete.
Correct answer: B
Rationale: The correct intervention that should be included in the care plan for a client about to receive low-dose brachytherapy via a vaginal implant is to insert an indwelling urinary catheter. This is crucial to prevent bladder distention during brachytherapy, ensuring the treatment's effectiveness and the client's comfort. Removing vaginal packing (Choice A) may not be necessary or appropriate in this situation. Ambulating the client four times daily (Choice C) is a good nursing intervention for general patient care but is not specifically related to brachytherapy via a vaginal implant. Keeping the client NPO until therapy is complete (Choice D) is not necessary unless specifically indicated due to the treatment's nature or the client's condition.
3. A client with a new diagnosis of Crohn's disease is being taught about dietary management by a nurse. Which of the following instructions should the nurse include?
- A. Eat foods that are high in fiber.
- B. Avoid dairy products to reduce diarrhea.
- C. Eat small, frequent meals to reduce symptoms.
- D. You should increase your intake of whole grains.
Correct answer: C
Rationale: The correct instruction the nurse should include is to advise the client to eat small, frequent meals to reduce symptoms of Crohn's disease. This eating pattern can help manage symptoms by reducing the workload on the digestive system. Choice A is incorrect because foods high in fiber can aggravate symptoms in Crohn's disease. Choice B is incorrect because not all individuals with Crohn's disease need to avoid dairy products, and it is not a universal recommendation. Choice D is incorrect because increasing whole grains may not be suitable for everyone with Crohn's disease, as it can worsen symptoms in some cases.
4. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Serous drainage on the dressing
- C. Temperature 37.3°C (99.1°F)
- D. Calf pain on dorsiflexion
Correct answer: D
Rationale: The correct answer is D. Calf pain on dorsiflexion following knee surgery may indicate a complication such as deep vein thrombosis, which is a serious condition requiring medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal range for a client post knee surgery and do not typically indicate immediate complications that require urgent reporting.
5. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?
- A. Flush the tube with 10 mL of water after feeding
- B. Flush the tube with 30 mL of water before feeding
- C. Place the client in a left lateral position
- D. Place the feeding bag 61 cm (24 in) above the client's abdomen
Correct answer: B
Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.
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