ATI RN
ATI Exit Exam 2024
1. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?
- A. Heart rate 90/min.
- B. WBC count 15,000/mm3.
- C. Urinary output 75 mL in the past 4 hours.
- D. Temperature 37.8°C (100°F).
Correct answer: B
Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.
2. A client requires seclusion to prevent harm to others on the unit. What action should the nurse take?
- A. Offer fluids every 2 hours.
- B. Document the client's behavior prior to being placed in seclusion.
- C. Discuss the client's inappropriate behavior prior to seclusion.
- D. Assess the client's behavior every hour.
Correct answer: B
Rationale: The correct answer is to document the client's behavior prior to being placed in seclusion. Documenting the behavior is crucial as it ensures that the decision to use seclusion is based on appropriate justifications and helps in monitoring the client's progress and response to the intervention. Offering fluids every 2 hours (Choice A) is not directly related to the need for seclusion. Discussing the client's behavior prior to seclusion (Choice C) may not be appropriate at the moment when immediate action is required to prevent harm. Assessing the client's behavior every hour (Choice D) is important but not as immediate as documenting the behavior prior to seclusion.
3. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Contact the client's family about the incident.
Correct answer: A
Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.
4. A nurse is caring for a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Decreased bilirubin levels
- B. Decreased prothrombin time
- C. Decreased albumin levels
- D. Increased prothrombin time
Correct answer: D
Rationale: In clients with cirrhosis, the liver is unable to produce clotting factors efficiently, leading to impaired clotting function. Therefore, an increased prothrombin time is expected in cirrhosis. Choices A, B, and C are incorrect. Decreased bilirubin levels are not typically seen in cirrhosis; prothrombin time is usually increased, not decreased; and albumin levels are often decreased in cirrhosis due to reduced synthetic liver function.
5. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?
- A. Avoid eating spinach while taking this medication.
- B. Massage the injection site after administration.
- C. Administer the injection into the deltoid muscle.
- D. Inject the medication into the abdomen.
Correct answer: D
Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.
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