ATI Exit Exam RN

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A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?

  • A. I will increase my intake of canned vegetables.
  • B. I will limit my daily sodium intake to 2 grams.
  • C. I will increase my intake of whole grains.
  • D. I will reduce my intake of processed meats.
Correct Answer: D

Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.

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A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

  • A. Place the client in a negative pressure room.
  • B. Wear a surgical mask when entering the client's room.
  • C. Place the client in droplet isolation.
  • D. Place a surgical mask on the client when transporting them.
Correct Answer: A

Rationale: The correct answer is to place the client in a negative pressure room. This action is necessary to prevent the spread of tuberculosis, as it is transmitted via airborne particles. Placing the client in droplet isolation (choice C) is not sufficient for tuberculosis, as it requires airborne precautions. Wearing a surgical mask (choice B) when entering the client's room may not provide adequate protection against airborne transmission. Placing a surgical mask on the client when transporting them (choice D) does not address the need for environmental controls to contain infectious particles.

A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

  • A. Increased appetite
  • B. Dry mucous membranes
  • C. Hypotension
  • D. Hyperreflexia
Correct Answer: C

Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.

What is the best nursing intervention for a patient experiencing fluid overload?

  • A. Administer diuretics
  • B. Administer IV fluids
  • C. Provide oral fluids
  • D. Provide chest physiotherapy
Correct Answer: A

Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.

A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

  • A. Blow as hard as possible into the mouthpiece.
  • B. Exhale quickly and forcefully after taking a deep breath.
  • C. Inhale as deeply as possible and then blow into the mouthpiece.
  • D. Take a deep breath and hold it for 5 seconds before exhaling.
Correct Answer: B

Rationale: The correct answer is B because the client should exhale quickly and forcefully into the peak flow meter after taking a deep breath to measure peak expiratory flow. Choice A is incorrect as blowing as hard as possible may not provide an accurate reading. Choice C is incorrect because inhaling deeply before blowing can affect the results. Choice D is incorrect as holding the breath before exhaling is not part of using a peak flow meter.

A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?

  • A. Massage the affected extremity every 4 hours.
  • B. Encourage the client to remain on bed rest.
  • C. Apply cold packs to the affected extremity.
  • D. Encourage the client to ambulate frequently.
Correct Answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.

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