ATI RN
ATI Comprehensive Predictor 2023 Exit Exam B Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a new diagnosis of rheumatoid arthritis. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Morning stiffness lasting more than 30 minutes is a hallmark symptom of rheumatoid arthritis, caused by joint inflammation and synovial fluid accumulation overnight.
Choice B is incorrect because rheumatoid arthritis typically causes symmetrical joint pain, not unilateral pain, which is more common in osteoarthritis or injury.
Choice C is incorrect because a fever of 38.5°C is not typical unless there is an infection or systemic complication, not a primary feature of rheumatoid arthritis.
Choice D is incorrect because bradycardia is not associated with rheumatoid arthritis; tachycardia may occur with inflammation or pain.
Question 2 of 5
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
Correct Answer: A
Rationale: Documenting the client's condition every 15 minutes is a crucial part of using restraints. Regular documentation helps ensure the safety and well-being of the client, as it allows for continuous monitoring and timely intervention if necessary. Requesting a PRN (as needed) restraint prescription for clients who are aggressive is not a recommended practice. Restraints should only be used as a last resort and must be based on a thorough assessment of the client's condition, not solely on their behavior. Attaching the restraint to the bed's side rails is not recommended. This can increase the risk of injury to the client. Restraints should be attached to a part of the bed frame that moves with the client, such as the head or footboard. While it's important to regularly check and adjust restraints for comfort and safety, there's no specific guideline that restraints should be removed every 4 hours. The frequency of removal and repositioning will depend on the individual client's condition and needs.
Question 3 of 5
A nurse is caring for a client who is receiving a unit of packed RBCs. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Verifying the client's identity with two nurses before starting the transfusion is a critical safety measure to prevent transfusion errors, such as administering blood to the wrong client, which can lead to severe complications like hemolytic reactions.
Choice A is wrong because checking the client's temperature 1 hour after the transfusion is not a standard requirement; temperature should be monitored before, during (especially the first 15 minutes), and at the completion of the transfusion to detect febrile reactions.
Choice B is wrong because infusing packed RBCs over 6 hours exceeds the recommended time frame (typically 2-4 hours) and increases the risk of bacterial contamination or hemolysis.
Choice D is wrong because administering a diuretic prior to the transfusion is not routinely indicated unless the client has a specific condition like heart failure or fluid overload, which would be determined by the provider.
Question 4 of 5
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Correct Answer: C
Rationale: Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up. Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field. Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution. Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills.
Question 5 of 5
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: Bright red urine with clots indicates potential active bleeding or clot obstruction in the bladder, a serious complication after TURP that requires immediate reporting to the provider.
Choice A is incorrect because a urine output of 200 mL/hr is within the expected range with continuous bladder irrigation, which produces high output to keep the bladder clear.
Choice C is incorrect because bladder spasms are common after TURP due to catheter irritation and can be managed with medications like oxybutynin, not requiring immediate reporting unless severe.
Choice D is incorrect because irrigation fluid inflow equal to outflow is a normal finding, indicating the system is functioning properly.