ATI RN
ATI RN Exit Exam Test Bank Questions
Question 1 of 5
A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.
Question 2 of 5
A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory findings should the nurse report to the provider?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Blood glucose level of 120 mg/dL. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high concentrations of glucose. Elevated blood glucose levels can indicate complications such as hyperglycemia, which can lead to adverse effects like electrolyte imbalances, infections, and hyperosmolar hyperglycemic state. Option A) Prealbumin level of 20 mg/dL and option B) Serum albumin level of 3.5 g/dL are not directly related to TPN administration. These levels reflect a client's nutritional status over a longer period and are not typically affected by short-term TPN therapy. Option C) Serum sodium level of 138 mEq/L is within the normal range and does not specifically indicate issues related to TPN administration. Educationally, it is vital for nurses to understand the implications of TPN therapy, including the need for close monitoring of blood glucose levels to prevent complications. By grasping the significance of specific lab values in TPN therapy, nurses can provide safe and effective care to clients receiving this specialized form of nutrition support.
Question 3 of 5
While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?
Correct Answer: D
Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.
Question 4 of 5
A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.
Question 5 of 5
A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C. 1+ protein in the urine is indicative of worsening preeclampsia and should be reported to the provider immediately. Elevated blood pressure (choice A) is expected in preeclampsia, but a reading of 120/80 mm Hg is within the normal range. A respiratory rate of 16/min (choice B) and a heart rate of 88/min (choice D) are also within normal limits and not indicative of worsening preeclampsia.