ATI RN
ATI Exit Exam RN
1. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
- A. Place the infant under a radiant warmer
- B. Move the probe site every 3 hours
- C. Heat the skin one minute prior to placing the probe
- D. Place a sensor on the index finger
Correct answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.
2. A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Bowel sounds present in all four quadrants
- B. Temperature of 37.5°C (99.5°F)
- C. Scant urine output
- D. Serosanguineous wound drainage
Correct answer: D
Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.
3. What is the most concerning electrolyte imbalance for a patient receiving digoxin?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct answer: B
Rationale: The correct answer is Hypokalemia. Hypokalemia is the most concerning electrolyte imbalance for a patient receiving digoxin because it can increase the risk of digoxin toxicity. Low potassium levels can potentiate the effects of digoxin on the heart, leading to serious cardiac arrhythmias. Hyperkalemia (Choice A) is not typically associated with digoxin use. Hyponatremia (Choice C) and Hypercalcemia (Choice D) are not directly related to digoxin therapy and do not pose the same risk of toxicity.
4. What is the best way to monitor for infection in a patient with a central line?
- A. Check the central line site daily
- B. Monitor the patient's vital signs
- C. Check the central line dressing every other day
- D. Check for signs of sepsis
Correct answer: A
Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.
5. A nurse is caring for a client who has deep vein thrombosis. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day.
- B. Avoid massaging the affected extremity to relieve pain.
- C. Do not apply cold packs to the client's affected extremity.
- D. Elevate the client's affected extremity when in bed.
Correct answer: D
Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.
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