ATI RN
ATI RN Comprehensive Exit Exam
1. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?
- A. Massage the client's legs every 2 hours.
- B. Encourage the client to remain on bed rest.
- C. Apply sequential compression devices to the client's legs.
- D. Administer anticoagulants as prescribed.
Correct answer: C
Rationale: The correct action the nurse should implement is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Massaging the client's legs may dislodge a clot and is contraindicated in this situation (choice A). Encouraging bed rest may increase the risk of DVT due to prolonged immobility (choice B). While administering anticoagulants is a common treatment for DVT, in this case, the question is about preventive measures, and using sequential compression devices is a non-pharmacological approach.
2. A client who has a new prescription for lithium is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have my blood levels checked regularly while taking this medication.
- B. I should take this medication on an empty stomach.
- C. I should avoid eating foods that are high in sodium.
- D. I should stop taking this medication if I experience nausea.
Correct answer: A
Rationale: The correct answer is A. Clients prescribed lithium need regular monitoring of blood levels to ensure the medication's effectiveness and safety. This monitoring helps to keep the medication within the therapeutic range and prevent toxicity. Choice B is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Choice C is not directly related to lithium therapy; however, excessive sodium intake can affect lithium levels. Choice D is incorrect as abruptly stopping lithium can lead to adverse effects and should only be done under healthcare provider guidance.
3. A nurse is assessing a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse expect?
- A. Diarrhea
- B. Muscle weakness
- C. Hypertension
- D. Bradycardia
Correct answer: B
Rationale: Muscle weakness is a common finding in clients with hypokalemia, as potassium is essential for proper muscle function. Diarrhea (choice A) is more commonly associated with hyperkalemia rather than hypokalemia. Hypertension (choice C) is not typically a direct result of low potassium levels. Bradycardia (choice D) is more commonly associated with hyperkalemia, not hypokalemia.
4. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
- A. Position the client on their left side.
- B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
- C. Hold the container of the enema solution 61 cm (24 in) above the client.
- D. Advance the enema tubing 15 cm (6 in) into the client's rectum.
Correct answer: C
Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.
5. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?
- A. Check the client's respiratory rate.
- B. Administer naloxone.
- C. Check the client's pain level.
- D. Assess the client's blood pressure.
Correct answer: A
Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.
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