ATI RN
ATI RN Exit Exam Quizlet
1. Which lab value should be closely monitored for a patient receiving heparin therapy?
- A. Monitor aPTT
- B. Monitor INR
- C. Monitor potassium levels
- D. Monitor sodium levels
Correct answer: A
Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.
2. A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Administer nitroglycerin sublingually.
- C. Obtain a 12-lead ECG.
- D. Notify the healthcare provider.
Correct answer: C
Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.
3. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative may indicate the client is struggling to bond, requiring intervention. Choices A, B, and C do not raise concerns about the bonding process between the client and the newborn. Holding the newborn in an en face position is a positive interaction. Asking the father to change the newborn's diaper involves family participation in care. Requesting the nurse to take the newborn to the nursery so she can rest is a valid request for maternal self-care.
4. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?
- A. Perform perineal care before the procedure.
- B. Apply sterile gloves before cleansing the perineal area.
- C. Place the client in a supine position.
- D. Lubricate the catheter with alcohol-based gel.
Correct answer: B
Rationale: Before inserting an indwelling urinary catheter for a female client, the nurse should apply sterile gloves before cleansing the perineal area to prevent infection. Performing perineal care before the procedure is incorrect as it should be done after catheter insertion. Placing the client in a side-lying position is not necessary for this procedure. Lubricating the catheter with petroleum jelly is not recommended as it can damage the catheter; using a water-soluble lubricant is preferred.
5. What is the most important nursing intervention for a patient with a suspected pulmonary embolism?
- A. Administer anticoagulants
- B. Administer oxygen
- C. Reposition the patient
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The most important nursing intervention for a patient with a suspected pulmonary embolism is to administer anticoagulants. Anticoagulants help prevent further clot formation in the patient's blood vessels, reducing the risk of complications such as worsening of the pulmonary embolism or development of new clots. Administering oxygen (Choice B) may be necessary to support the patient's oxygenation, but anticoagulants take precedence as they target the underlying cause of the pulmonary embolism. Repositioning the patient (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of patient care but are not the primary intervention for a suspected pulmonary embolism.
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