a charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney
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Nursing Elites

ATI RN

ATI Exit Exam 2023

1. When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

Correct answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

2. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy?

Correct answer: C

Rationale: The correct answer is C: Tetanus diphtheria and acellular pertussis (Tdap) vaccine. The Tdap vaccine can be safely administered during pregnancy to protect both the mother and the newborn against whooping cough. Choices A, B, and D are incorrect because the Varicella vaccine, Inactivated polio vaccine, and Inactivated influenza vaccine are generally not recommended during pregnancy due to safety concerns.

3. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Choosing fresh fruits and vegetables is a healthy choice for someone with hypertension as they are low in sodium and high in nutrients. Processed meats (A) are high in sodium and unhealthy fats, which can worsen hypertension. Canned vegetables (B) often have added sodium, so fresh is a better choice. Canned soups (D) are typically high in sodium and should be limited in a hypertensive diet.

4. A client who is 48 hours postoperative following abdominal surgery is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: Sanguineous drainage from the surgical site 48 hours after surgery could indicate a complication such as hemorrhage or infection and should be reported. Sanguineous drainage is typically seen in the early postoperative period due to the presence of blood. Serous drainage, on the other hand, is normal in the later stages of wound healing. A heart rate of 80/min is within the normal range for an adult. A temperature of 37.5°C (99.5°F) is slightly elevated but not a concerning finding in the absence of other symptoms.

5. A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory values should the nurse monitor?

Correct answer: D

Rationale: The correct answer is D, INR. The International Normalized Ratio (INR) is used to monitor the therapeutic effect of warfarin and to adjust the dose as needed. While Prothrombin time (PT) and activated Partial Thromboplastin Time (aPTT) are also related to coagulation studies, monitoring INR specifically helps in managing warfarin therapy. Hemoglobin, on the other hand, is not typically monitored in relation to warfarin therapy.

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