ATI RN
ATI RN Exit Exam Test Bank
1. What is the priority nursing assessment for a patient who has just returned from surgery?
- A. Monitor respiratory rate
- B. Monitor blood pressure
- C. Check the surgical site
- D. Monitor heart rate
Correct answer: A
Rationale: The correct answer is to monitor the patient's respiratory rate. This assessment is essential as it ensures that the patient is breathing adequately post-surgery. Maintaining a patent airway and adequate oxygenation are the top priorities in the immediate postoperative period. Monitoring blood pressure, checking the surgical site, or monitoring heart rate are important assessments but are not the priority immediately upon the patient's return from surgery.
2. A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Obtain a 12-lead ECG.
- C. Administer nitroglycerin sublingually.
- D. Notify the provider.
Correct answer: B
Rationale: The correct answer is to obtain a 12-lead ECG. In a client with a history of angina and reporting chest pain, the priority action is to assess for myocardial infarction, which is best done through an ECG. Administering oxygen, nitroglycerin, or notifying the provider can be important actions but obtaining an ECG takes precedence in evaluating the client's condition.
3. What lab value should a healthcare provider monitor for a patient on warfarin therapy?
- A. Potassium
- B. PT/INR
- C. Sodium
- D. Calcium
Correct answer: B
Rationale: The correct answer is B: PT/INR. When a patient is on warfarin therapy, healthcare providers monitor the PT/INR levels to evaluate the effectiveness of the treatment and assess the risk of bleeding. Monitoring potassium, sodium, or calcium levels is not directly related to warfarin therapy and would not provide the necessary information needed to manage the medication effectively.
4. While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?
- A. Monitor the client's urinary output.
- B. Check the client's blood pressure.
- C. Assess the client for constipation.
- D. Monitor the client's respiratory rate.
Correct answer: D
Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.
5. What is the most important assessment for a patient with respiratory distress?
- A. Monitor oxygen saturation
- B. Check for abnormal breath sounds
- C. Check for pitting edema
- D. Perform a neurological exam
Correct answer: A
Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.
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