ATI RN
ATI Comprehensive 2024 Exit Exam with NGN Questions
Extract:
A nurse manager is updating protocols for the use of belt restraints.
Question 1 of 5
Which of the following guidelines should the nurse manager include?
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to monitor the client's well-being, detect any changes promptly, and ensure the effectiveness of the restraint. Removing the restraint every 4 hours (choice
A) can compromise the client's safety and defeat the purpose of using restraints. Requesting a PRN restraint prescription for aggressive clients (choice
C) may lead to overuse of restraints without proper assessment. Attaching restraints to the bed's side rails (choice
D) can increase the risk of injury and is not recommended. Regular documentation is essential in ensuring the client's safety and well-being.
Extract:
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit.
Question 2 of 5
Which of the following statements should the nurse include in the hand-off report?
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 milliliters. This statement is crucial in a hand-off report as it provides important information about the client's condition post-procedure. It helps alert the receiving nurse to any potential complications or the need for further monitoring.
Statement B is incorrect as the client's position on the board of directors is not relevant to the client's immediate care needs and does not provide useful clinical information. Statement C, the number of sponges used, is also irrelevant to the client's immediate condition and does not impact the client's ongoing care.
Statement D, mentioning intubation without complications, could be important in certain contexts, but in this scenario, information about blood loss is more critical for the receiving nurse to be aware of.
Extract:
A nurse in an emergency department is caring for a client who has a closed head injury.
Question 3 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (
B) or administering mannitol IV bolus (
C) may be needed but assessing neurological status comes first. Preparing for an MRI (
D) is important but not the initial step.
Extract:
A nurse in an emergency department is caring for a client following a motor-vehicle crash.
Question 4 of 5
Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (
B) is a basic response but does not indicate orientation. Inability to obey commands (
C) suggests altered mental status. Withdrawing from pain (
D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.
Extract:
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R interval of 0.35 seconds.
Question 5 of 5
Which of the following dysrhythmias is the client displaying?
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. This dysrhythmia is characterized by a delay in conduction at the atrioventricular node, causing a prolonged PR interval (>0.20 sec) on ECG. It is a benign condition and does not typically require treatment unless symptomatic.
Choices B and D are more serious dysrhythmias that have different ECG patterns and clinical implications. Complete heart block (
Choice
B) presents with a lack of conduction between the atria and ventricles, leading to a slow ventricular rate. Atrial fibrillation (
Choice
D) is characterized by rapid, irregular atrial depolarizations without effective atrial contractions. Premature atrial complexes (
Choice
C) are early ectopic atrial beats that appear as abnormal P waves on ECG but do not cause significant conduction delays.