ATI RN
ATI RN Exit Exam 2023
1. A client with a new diagnosis of heart failure is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Limit sodium intake to 4 grams per day.
- B. Weigh yourself daily to monitor for fluid retention.
- C. Drink 2 liters of water each day.
- D. Increase physical activity gradually.
Correct answer: B
Rationale: The correct answer is B. Weighing oneself daily is crucial in monitoring fluid retention, a key aspect in managing heart failure. This helps in detecting early signs of fluid buildup, prompting timely interventions. Choice A is incorrect as the recommended sodium intake for heart failure clients is usually lower, around 2-3 grams daily. Choice C is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice D is incorrect as clients with heart failure should consult healthcare providers before significantly altering their physical activity levels.
2. A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?
- A. Shave the hair at the insertion site.
- B. Cleanse the site with povidone-iodine.
- C. Wear sterile gloves when changing the dressing.
- D. Change the IV site every 48 to 72 hours.
Correct answer: D
Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.
3. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?
- A. Monitor the client's urinary output.
- B. Assist the client to splint the incision with a pillow when coughing.
- C. Provide the client with a clear liquid diet.
- D. Encourage the client to ambulate in the hallway.
Correct answer: B
Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.
4. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?
- A. Fatigue
- B. Nausea
- C. Skin irritation
- D. Weight gain
Correct answer: C
Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.
5. A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?
- A. Administer thickened liquids.
- B. Provide small bites of food.
- C. Encourage the client to eat quickly to avoid fatigue.
- D. Have the client lie supine after meals.
Correct answer: A
Rationale: The correct intervention for a client with dysphagia is to administer thickened liquids. Thickened liquids help prevent aspiration, which is a common risk for clients with swallowing difficulties. Providing small bites of food (choice B) can help, but the priority is to modify the liquid consistency. Encouraging the client to eat quickly (choice C) is not recommended as it may increase the risk of aspiration and fatigue. Having the client lie supine after meals (choice D) can actually increase the risk of aspiration, especially in clients with dysphagia.
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