ATI RN
ATI RN Comprehensive Exit Exam 2023
1. How should signs of dehydration in an elderly patient be assessed?
- A. Monitor skin turgor
- B. Check for dry mucous membranes
- C. Monitor for sunken eyes
- D. Check capillary refill
Correct answer: A
Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.
2. How should a healthcare professional assess for fluid overload in a patient with heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor blood pressure
- D. Check oxygen saturation
Correct answer: A
Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.
3. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?
- A. Heart rate of 90/min
- B. Blood pressure of 118/76 mm Hg
- C. Warmth and redness in the calf
- D. Pink-tinged urine
Correct answer: C
Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.
4. What is the priority nursing intervention for a patient experiencing a myocardial infarction?
- A. Administer aspirin
- B. Administer nitroglycerin
- C. Administer morphine
- D. Prepare for surgery
Correct answer: A
Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.
5. A client with a new diagnosis of diabetes mellitus is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will eat a bedtime snack if my blood sugar is below 200 mg/dL.
- B. I will eat more sugar-free candy to help control my blood sugar.
- C. I will check my blood sugar every morning before breakfast.
- D. I will avoid physical activity if my blood sugar is below 100 mg/dL.
Correct answer: C
Rationale: The correct answer is C because checking blood sugar levels every morning before breakfast is a crucial aspect of managing diabetes effectively. This practice helps individuals monitor their blood sugar levels regularly and adjust their treatment plan as needed. Option A is incorrect as consuming a bedtime snack based on blood sugar levels alone may not be an appropriate approach to managing diabetes. Option B is incorrect as relying on more sugar-free candy does not address the overall dietary management of blood sugar levels. Option D is incorrect as avoiding physical activity when blood sugar is below 100 mg/dL can hinder diabetes management, as exercise is generally beneficial for controlling blood sugar levels.
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