ATI Exit Exam RN

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A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

  • A. Auscultate the apical pulse and count for 1 minute
  • B. Place a sensor on the index finger
  • C. Heat the skin prior to placing the probe
  • D. Recheck after 10 minutes
Correct Answer: A

Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.

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A client at risk for osteoporosis is being taught by a nurse about dietary measures to increase calcium intake. Which of the following foods should the nurse recommend?

  • A. Carrots
  • B. Cottage cheese
  • C. Bananas
  • D. Broccoli
Correct Answer: D

Rationale: The correct answer is D: Broccoli. Broccoli is high in calcium, making it a suitable recommendation for clients at risk for osteoporosis. Carrots, Cottage cheese, and Bananas are not significant sources of calcium compared to broccoli, and therefore, they are not the best choices to increase calcium intake.

A client with asthma is prescribed a corticosteroid inhaler. Which of the following instructions should the nurse include?

  • A. Use the inhaler as needed for acute symptoms.
  • B. Rinse the mouth after each use.
  • C. Take the medication only during asthma attacks.
  • D. Administer a bronchodilator after using the corticosteroid.
Correct Answer: B

Rationale: The correct instruction is to rinse the mouth after each use of a corticosteroid inhaler to prevent oral candidiasis (thrush). Choice A is incorrect because corticosteroid inhalers are usually used on a regular schedule to control asthma symptoms, not just for acute symptoms. Choice C is incorrect as corticosteroid inhalers are typically used for long-term management, not just during asthma attacks. Choice D is incorrect as administering a bronchodilator after using a corticosteroid is not a standard practice and is not necessary for the effectiveness of the corticosteroid inhaler.

A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

  • A. Platelets 250,000/mm³
  • B. aPTT 60 seconds
  • C. Hemoglobin 15 g/dL
  • D. INR 1.5
Correct Answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

  • A. Provide a low-sodium diet.
  • B. Administer lorazepam as prescribed.
  • C. Keep the client in a supine position.
  • D. Place the client in restraints as prescribed.
Correct Answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

  • A. Encourage the client to take deep breaths.
  • B. Administer oxygen as needed.
  • C. Teach the client pursed-lip breathing.
  • D. Limit the client's fluid intake.
Correct Answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

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