ATI Comprehensive Exit Exam Test Bank

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A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?

  • A. Keep track of calorie intake for food and beverages.
  • B. Provide a low-protein, high-carbohydrate diet.
  • C. Schedule meals at 6-hour intervals.
  • D. Provide a high-protein, high-calorie diet.
Correct Answer: D

Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.

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A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

  • A. Take this medication at bedtime.
  • B. Take your pulse before taking this medication.
  • C. Avoid eating foods high in potassium.
  • D. Take this medication with an antacid.
Correct Answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.

A nurse is reviewing the medical history of a client who has angina. What risk factor should the nurse identify?

  • A. Hyperlipidemia.
  • B. COPD.
  • C. Seizure disorder.
  • D. Hyponatremia.
Correct Answer: A

Rationale: The correct answer is A, Hyperlipidemia. Hyperlipidemia, characterized by high levels of lipids in the blood, is a well-established risk factor for the development of angina. Elevated lipid levels can lead to atherosclerosis, which narrows the arteries supplying the heart muscle with oxygenated blood, increasing the risk of angina. Choices B, C, and D are incorrect because COPD, seizure disorder, and hyponatremia are not directly associated with an increased risk of angina.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

  • A. Check the client's identification band
  • B. Verify the provider's prescription
  • C. Prime the IV tubing with 0.9% sodium chloride
  • D. Obtain the client's vital signs
Correct Answer: A

Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.

A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?

  • A. Denial
  • B. Bargaining
  • C. Acceptance
  • D. Anger
Correct Answer: B

Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'

A nurse is reviewing the medical record of a client who has a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?

  • A. Blood pressure 110/70 mm Hg
  • B. Heart rate 88/min
  • C. Serum potassium 3.2 mEq/L
  • D. Sodium 136 mEq/L
Correct Answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L is below the normal range, indicating hypokalemia. Before administering potassium chloride, which is used to treat low potassium levels, the nurse should report this finding to the provider for further evaluation and potential adjustment of the treatment plan. Choices A, B, and D are within normal ranges and do not directly relate to the need for potassium chloride administration.

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