a nurse is reviewing a clients laboratory results which of the following values is a contraindication to the administration of heparin
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A healthcare professional is reviewing a client's laboratory results. Which of the following values is a contraindication to the administration of heparin?

Correct answer: B

Rationale: The correct answer is B: Platelet count 50,000/mm³. A platelet count of 50,000/mm³ increases the risk of bleeding, making heparin contraindicated. Platelets are essential for blood clotting, and a low count can lead to excessive bleeding. Choices A, C, and D are not contraindications to heparin administration. Hemoglobin level of 13 g/dL is within the normal range, white blood cell count of 6,000/mm³ is also normal, and an INR of 2.5 is within the therapeutic range for patients receiving heparin therapy.

2. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

Correct answer: C

Rationale: Respecting cultural preferences promotes trust and client-centered care.

3. What is the primary nursing action for a patient with confusion post-surgery?

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

4. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

5. A healthcare provider is reviewing the medical record of a client who has Cushing's disease. Which of the following findings should the healthcare provider expect?

Correct answer: C

Rationale: In Cushing's disease, there is increased cortisol production, which can lead to various metabolic disturbances. One of the common findings is an increased serum potassium level. The other options are incorrect because Cushing's disease typically causes hyperglycemia, not decreased serum glucose levels (A), lymphocytopenia, not increased lymphocyte count (B), and hyponatremia, not decreased serum sodium level (D).

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