ATI RN
ATI RN Comprehensive Exit Exam 2023
1. A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself every morning.
- B. I should drink 2 liters of water each day.
- C. I should avoid all physical activity.
- D. I should take an extra dose of diuretic if I gain 2 pounds in a day.
Correct answer: A
Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.
2. A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Weigh the client weekly to monitor for fluid retention.
- B. Monitor the client's blood glucose level every 6 hours.
- C. Change the TPN tubing every 72 hours.
- D. Flush the TPN line with sterile water before and after administration.
Correct answer: B
Rationale: The correct answer is B: Monitor the client's blood glucose level every 6 hours. When a client is on TPN, it is crucial to monitor their blood glucose levels frequently to prevent complications such as hyperglycemia or hypoglycemia. Weighing the client weekly to monitor for fluid retention (choice A) is important but not as critical as monitoring blood glucose levels. Changing the TPN tubing every 72 hours (choice C) is important for infection control but does not directly relate to the client's metabolic status. Flushing the TPN line with sterile water before and after administration (choice D) is not a standard practice and may introduce contaminants into the TPN solution.
3. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Apply a dry dressing.
- B. Cleanse the wound with normal saline.
- C. Perform debridement as needed.
- D. Apply a hydrocolloid dressing.
Correct answer: D
Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.
4. What is the most appropriate intervention for a patient experiencing hypoglycemia?
- A. Administer glucagon
- B. Provide oral glucose
- C. Administer IV fluids
- D. Monitor blood sugar levels
Correct answer: B
Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.
5. A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?
- A. Take this medication in the evening before bed.
- B. Take this medication on an empty stomach.
- C. Take this medication with a full glass of milk.
- D. Take this medication with an antacid if you experience indigestion.
Correct answer: B
Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.
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