ATI RN
ATI Exit Exam RN
1. What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?
- A. Administer anticoagulants
- B. Encourage ambulation
- C. Apply compression stockings
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.
2. A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?
- A. Avoid eating small, frequent meals.
- B. Sleep with the head of your bed elevated.
- C. Lie down after eating.
- D. Avoid drinking fluids with meals.
Correct answer: B
Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.
3. A nurse is caring for a client who has acute pancreatitis. Which of the following interventions should the nurse take?
- A. Encourage oral intake of clear liquids
- B. Administer an antiemetic before meals
- C. Insert a nasogastric tube for suction
- D. Place the client in a supine position
Correct answer: C
Rationale: In acute pancreatitis, the gastrointestinal tract needs to rest to reduce pancreatic enzyme secretion. Inserting a nasogastric tube for suction helps decompress the stomach and reduce stimulation of the pancreas. Encouraging oral intake of clear liquids (Choice A) or administering an antiemetic before meals (Choice B) may aggravate the condition by stimulating the pancreas. Placing the client in a supine position (Choice D) may not directly address the underlying issue of reducing pancreatic stimulation.
4. A nurse is providing teaching about digoxin administration to the parents of a toddler with heart failure. Which of the following statements should the nurse include?
- A. Limit your child's potassium intake while taking this medication.
- B. You can mix the medication with a half-cup of your child's favorite juice.
- C. Do not repeat the dose if your child vomits within one hour after taking the medication.
- D. Have your child drink a small glass of water after swallowing the medication.
Correct answer: D
Rationale: The correct statement to include in the teaching about digoxin administration is to have the child drink a small glass of water after swallowing the medication. Water helps flush down the medication, preventing irritation in the esophagus. Choice A is incorrect because digoxin may interact with potassium levels, but strict restriction is not necessary. Choice B is incorrect as medications should not be mixed with juices unless specified by the healthcare provider due to possible interactions. Choice C is incorrect because if a child vomits after taking digoxin, the dose should not be repeated to avoid double dosing.
5. A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?
- A. Place the client's dentures in a labeled container
- B. Remove the client's IV lines
- C. Place the client's body in a semi-fowler's position
- D. Lower the client's head of the bed
Correct answer: B
Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.
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