ATI RN
ATI Exit Exam 2023 Quizlet
1. A client who is postoperative following a total hip arthroplasty is at risk for hip dislocation. Which of the following actions should the nurse take to prevent this complication?
- A. Position the client supine with a pillow between the legs
- B. Place a pillow under the client's knees
- C. Place an abduction pillow between the client's legs
- D. Place a trochanter roll under the client's legs
Correct answer: C
Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents the hip from dislocating. This position aids in keeping the hip in a neutral or slightly outwardly rotated position, reducing the risk of dislocation. Placing the client supine with a pillow between the legs (Choice A) or using a trochanter roll (Choice D) may not provide the same level of abduction and support needed to prevent hip dislocation. Placing a pillow under the client's knees (Choice B) does not provide the necessary support to maintain proper hip alignment in this situation.
2. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Peripheral edema.
- B. Cough with frothy sputum.
- C. Jugular vein distention.
- D. Dependent edema.
Correct answer: C
Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.
3. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
- A. Place the tip of the thermometer under the center of the infant's axilla.
- B. Pull the pinna of the infant's ear forward before inserting the probe.
- C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
- D. Insert the thermometer in front of the infant's tongue.
Correct answer: A
Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.
4. A nurse is preparing to administer insulin glargine to a client who has diabetes mellitus. Which of the following actions should the nurse take?
- A. Administer the insulin via IV push.
- B. Rotate injection sites to prevent tissue damage.
- C. Mix the insulin with regular insulin before administering it.
- D. Administer the insulin at the same time each day.
Correct answer: D
Rationale: Corrected Rationale: The correct action for the nurse to take when administering insulin glargine is to give it at the same time each day. This consistent timing helps maintain stable blood glucose levels. Choice A is incorrect because insulin glargine should not be administered via IV push. Choice B is incorrect as rotating injection sites is typically done for short-acting insulins to prevent lipodystrophy, not for insulin glargine. Choice C is incorrect as insulin glargine should not be mixed with other insulins before administration.
5. A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?
- A. Creatinine.
- B. Aspartate aminotransferase (AST).
- C. White blood cell count.
- D. Serum glucose.
Correct answer: A
Rationale: The correct answer is A: Creatinine. Gentamicin can cause nephrotoxicity, leading to impaired kidney function. Monitoring creatinine levels helps the nurse detect any potential kidney damage. Choice B, Aspartate aminotransferase (AST), is not typically affected by gentamicin. Choice C, White blood cell count, is not directly related to gentamicin adverse effects. Choice D, Serum glucose, is not specifically monitored for gentamicin adverse effects.
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