ATI RN
ATI RN Comprehensive Exit Exam
1. What is the best intervention for a patient with a suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Reposition the patient
- D. Administer bronchodilators
Correct answer: A
Rationale: Administering oxygen is the best intervention for a patient with a suspected pulmonary embolism because it helps alleviate respiratory distress and improve oxygenation. Oxygen therapy is crucial to ensure adequate oxygen levels in the blood due to the obstruction in the pulmonary circulation caused by the embolism. Administering anticoagulants (choice B) is a treatment for confirmed pulmonary embolism rather than a suspected case. Repositioning the patient (choice C) or administering bronchodilators (choice D) would not directly address the underlying issue of impaired gas exchange and oxygen delivery associated with pulmonary embolism.
2. How should a healthcare provider monitor a patient with fluid overload?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor input and output
- D. Monitor blood pressure
Correct answer: A
Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.
3. A nurse is reviewing the medical record of a client who has chronic kidney disease. The client's potassium level is 6.5 mEq/L. Which of the following actions should the nurse take?
- A. Administer sodium bicarbonate
- B. Administer sodium polystyrene sulfonate
- C. Administer calcium gluconate
- D. Administer calcium carbonate
Correct answer: B
Rationale: The correct answer is B: Administer sodium polystyrene sulfonate. Sodium polystyrene sulfonate is used to treat hyperkalemia by promoting the excretion of potassium. Choice A, administering sodium bicarbonate, is incorrect as it is not used to treat hyperkalemia. Choice C, administering calcium gluconate, is incorrect as it is used to treat hypocalcemia, not hyperkalemia. Choice D, administering calcium carbonate, is incorrect as it is used to treat conditions like osteoporosis and indigestion, not hyperkalemia.
4. What is the recommended dietary restriction for a patient with chronic kidney disease?
- A. Limit potassium intake
- B. Limit fluid intake
- C. Increase protein intake
- D. Increase carbohydrate intake
Correct answer: B
Rationale: The correct answer is to limit fluid intake for a patient with chronic kidney disease. This restriction helps manage fluid balance to prevent fluid overload. Choices A, C, and D are incorrect. Limiting potassium intake is essential for some patients with kidney disease, but it is not the primary dietary restriction. Increasing protein intake is usually not recommended due to the impaired kidney function in these patients. Increasing carbohydrate intake is also not a standard recommendation for patients with chronic kidney disease.
5. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?
- A. Place the client upright on a donut-shaped cushion.
- B. Teach the client to shift his weight every 15 minutes while sitting.
- C. Turn and reposition the client every 3 hours.
- D. Assess pressure points every 24 hours.
Correct answer: B
Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.
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