ATI RN
ATI RN Exit Exam Test Bank
1. Which lab value should be monitored in patients receiving heparin therapy?
- A. Monitor aPTT
- B. Monitor INR
- C. Monitor platelet count
- D. Monitor sodium levels
Correct answer: A
Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.
2. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?
- A. Elevate the head of the bed 45 degrees during feedings.
- B. Place the client in the left lateral position for 30 minutes after feedings.
- C. Flush the tube with 30 mL of sterile water before each feeding.
- D. Check gastric residuals every 8 hours.
Correct answer: A
Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.
3. A client with type 1 diabetes mellitus is receiving foot care education from a nurse. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Apply lotion to your feet after bathing.
- D. Trim toenails straight across.
Correct answer: D
Rationale: The correct answer is D: 'Trim toenails straight across.' In clients with diabetes, trimming toenails straight across is important to prevent ingrown toenails, reducing the risk of infections. Soaking feet in warm water daily (choice A) can lead to dry skin and potentially cause skin breakdown in diabetic clients. While wearing cotton socks (choice B) is beneficial for good foot hygiene, it is not as crucial as trimming toenails correctly. Applying lotion to feet after bathing (choice C) is helpful for moisturizing the skin, but the emphasis should be on nail care to prevent complications like ingrown toenails.
4. Which electrolyte imbalance is most concerning in a patient taking digoxin?
- A. Monitor potassium levels
- B. Monitor calcium levels
- C. Monitor sodium levels
- D. Monitor magnesium levels
Correct answer: A
Rationale: The correct answer is to monitor potassium levels. Patients taking digoxin are at risk of developing toxicity due to hypokalemia. Low potassium levels can potentiate the toxic effects of digoxin on the heart, leading to serious arrhythmias. Monitoring calcium levels (Choice B) is not the primary concern in patients taking digoxin. While calcium levels play a role in cardiac function, hypocalcemia is not directly associated with digoxin toxicity. Monitoring sodium levels (Choice C) is important for other conditions but is not the primary concern in a patient taking digoxin. Monitoring magnesium levels (Choice D) is also essential, but hypomagnesemia is not as directly linked to digoxin toxicity as hypokalemia.
5. A nurse is caring for a client who is at risk for developing a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?
- A. Massage the client's legs every 2 hours.
- B. Instruct the client to sit with the legs crossed.
- C. Administer prophylactic antibiotics.
- D. Apply sequential compression devices to the client's legs.
Correct answer: D
Rationale: The correct answer is D: Apply sequential compression devices to the client's legs. Sequential compression devices help prevent venous stasis and reduce the risk of DVT by promoting blood flow in the legs. Massaging the client's legs every 2 hours (choice A) may dislodge a clot if present, leading to a higher risk of embolism. Instructing the client to sit with the legs crossed (choice B) can impede blood flow and increase the risk of DVT. Administering prophylactic antibiotics (choice C) is not indicated for preventing DVT, as antibiotics are used to treat infections caused by bacteria, not to prevent blood clots.
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