ATI RN
ATI Exit Exam
1. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Auscultate the newborn's apical pulse for 60 seconds
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence
Correct answer: C
Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.
2. A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 78/min
- B. Oxygen saturation of 95%
- C. Urine output of 30 mL/hr
- D. Serosanguineous wound drainage
Correct answer: C
Rationale: In a postoperative client, a urine output of 30 mL/hr is a concerning finding as it indicates oliguria, which may suggest dehydration or kidney impairment. Adequate urine output is essential for monitoring renal function and overall fluid status. A heart rate of 78/min is within the normal range for an adult. An oxygen saturation of 95% is acceptable and indicates adequate oxygenation. Serosanguineous wound drainage is expected in the early postoperative period and is not a cause for immediate concern unless it becomes excessive or changes character.
3. A nurse is caring for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 120/80 mm Hg
- B. Weight gain of 0.9 kg (2 lb) in 1 week
- C. Urine output of 30 mL/hr
- D. Respiratory rate 16/min
Correct answer: B
Rationale: A weight gain of 0.9 kg (2 lb) in 1 week is an indication of fluid retention, which is concerning in a client with preeclampsia. This can be a sign of worsening condition requiring immediate medical attention. High blood pressure (option A) is expected in preeclampsia, a urine output of 30 mL/hr (option C) is decreased but not as urgent as the weight gain in this scenario, and a respiratory rate of 16/min (option D) is within normal limits.
4. During an in-service about nursing leadership, what information should the nurse include about an effective leader?
- A. Acts as an advocate for the nursing unit.
- B. Prioritizes staff requests over client needs.
- C. Shares personal opinions to influence the group's values.
- D. Provides routine client care and documentation.
Correct answer: A
Rationale: An effective leader advocates for the unit's success and its members. Choice B is incorrect because prioritizing staff requests over client needs does not align with effective leadership, which should focus on client-centered care. Choice C is incorrect as sharing personal opinions to influence the group's values can be biased and may not reflect the best interest of the team. Choice D is incorrect because while providing client care is essential, effective leadership involves more than routine tasks and includes guiding and supporting the team.
5. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?
- A. Increased appetite
- B. Pallor
- C. Tachycardia
- D. Hypertension
Correct answer: B
Rationale: The correct answer is B: Pallor. Pallor, which is paleness of the skin, is a common sign of anemia due to a decreased number of red blood cells or hemoglobin levels. This results in reduced oxygen-carrying capacity, leading to the paleness of the skin. Choice A, increased appetite, is not typically associated with anemia. Choice C, tachycardia (increased heart rate), can be present in anemia as the body compensates for decreased oxygenation. Choice D, hypertension (high blood pressure), is not a common finding in anemia; instead, low blood pressure may be observed due to decreased blood volume.
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