ATI RN
ATI RN Exit Exam
1. What is the appropriate nursing response when a patient refuses blood transfusion due to religious beliefs?
- A. Respect the patient's decision and notify the provider
- B. Attempt to persuade the patient to accept the transfusion
- C. Document the refusal and notify the healthcare provider
- D. Provide education on the benefits of blood transfusion
Correct answer: A
Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.
2. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Potassium 4.0 mEq/L
- B. Hemoglobin 12 g/dL
- C. BUN 18 mg/dL
- D. Sodium 137 mEq/L
Correct answer: B
Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.
3. A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 90/min
- B. Serum potassium level of 4.0 mEq/L
- C. Weight gain of 2 kg (4.4 lb) in 2 days
- D. Heart rate of 76/min
Correct answer: C
Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.
4. A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?
- A. Take one puff every 5 minutes until symptoms improve.
- B. Hold your breath for 10 seconds after inhaling the medication.
- C. Shake the inhaler for 2 seconds before use.
- D. Exhale forcefully after each puff.
Correct answer: B
Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.
5. What is the best intervention for a patient presenting with respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Reposition the patient
- D. Provide humidified air
Correct answer: A
Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.
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