ATI RN
ATI RN Comprehensive Exit Exam 2023
1. What is the most important nursing assessment for a patient with suspected deep vein thrombosis (DVT)?
- A. Check for leg pain
- B. Perform Homan's sign test
- C. Monitor for redness
- D. Assess for warmth and swelling
Correct answer: A
Rationale: The most important nursing assessment for a patient with suspected deep vein thrombosis (DVT) is to check for leg pain. Leg pain is a cardinal symptom of DVT and is often the initial indicator of a blood clot. While assessing for warmth, swelling, and redness are also important in DVT evaluation, leg pain is the most crucial as it can prompt further diagnostic testing and interventions. Performing Homan's sign test is no longer recommended due to its low specificity and potential to dislodge a clot, causing complications. Monitoring for redness is important but may not always be present in DVT cases. Assessing for warmth and swelling is relevant but still secondary to the assessment of leg pain in suspected DVT cases.
2. How should a healthcare provider manage a patient with a history of hypertension who is non-compliant with medication?
- A. Educate the patient on the importance of medication
- B. Reassess the patient in 6 months
- C. Refer the patient to a specialist
- D. Discontinue the medication
Correct answer: A
Rationale: Educating the patient on the importance of medication is crucial when dealing with a patient who is non-compliant with their hypertension medication. By providing information about the significance of the medication in controlling blood pressure and preventing complications, the patient may be more motivated to adhere to the prescribed treatment. Reassessing the patient in 6 months (choice B) may lead to further deterioration of the patient's condition if non-compliance continues. Referring the patient to a specialist (choice C) may be necessary in some cases but should be preceded by efforts to improve compliance. Discontinuing the medication (choice D) without addressing the non-compliance issue can have serious health consequences for the patient.
3. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 2 minutes with a duration of 90 seconds. Which of the following actions should the nurse take?
- A. Increase the oxytocin infusion.
- B. Maintain the oxytocin infusion.
- C. Discontinue the oxytocin infusion.
- D. Provide reassurance to the client.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. With contractions occurring every 2 minutes and lasting 90 seconds, this pattern indicates hyperstimulation, which can be harmful to the fetus. Discontinuing the oxytocin infusion is essential to prevent further harm. Increasing the oxytocin infusion would exacerbate the situation, maintaining it would continue the risk, and providing reassurance to the client, although important, does not address the need for immediate action to ensure the safety of the fetus.
4. 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.
5. A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?
- A. Promethazine
- B. Hydromorphone
- C. Ketorolac
- D. Amitriptyline
Correct answer: B
Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.
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