ATI RN
ATI RN Exit Exam 2023
1. When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will stop taking my medication once my blood pressure is within normal range.
- D. I will sit quietly for 5 minutes before measuring my blood pressure.
Correct answer: D
Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.
2. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?
- A. Calf tenderness.
- B. Shortness of breath.
- C. Elevated blood pressure.
- D. Respiratory rate of 18/min.
Correct answer: B
Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.
3. A nurse is assessing a client who is 1 day postoperative following hip replacement surgery. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Serosanguineous drainage on the surgical dressing
- C. Blood pressure of 118/76 mm Hg
- D. Urine output of 40 mL/hr
Correct answer: D
Rationale: The correct answer is D: Urine output of 40 mL/hr. A low urine output may indicate kidney complications, such as acute kidney injury, which is a critical finding postoperatively. The nurse should report this immediately to the provider for further evaluation and management. Choices A, B, and C are within normal limits for a client who is 1 day postoperative following hip replacement surgery and do not indicate immediate concerns that require reporting to the provider.
4. A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?
- A. Massage the injection site after administering the medication.
- B. Insert the needle at a 45° angle.
- C. Use a Z-track technique to administer the injection.
- D. Aspirate for blood before injecting the medication.
Correct answer: C
Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.
5. A client with heart failure is prescribed furosemide. What finding should the nurse report to the provider?
- A. Sodium 140 mEq/L
- B. Heart rate of 82/min
- C. Potassium level of 2.8 mEq/L
- D. Oxygen saturation 95%
Correct answer: C
Rationale: The correct answer is C. A potassium level of 2.8 mEq/L is low and should be reported to the provider. Furosemide can cause potassium depletion, leading to hypokalemia. Low potassium levels can result in cardiac dysrhythmias, which is a serious concern in clients with heart failure. Choices A, B, and D are within normal ranges and do not require immediate reporting. Sodium level of 140 mEq/L, heart rate of 82/min, and oxygen saturation of 95% are all acceptable findings.
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