ATI Exit Exam RN

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A nurse is caring for a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

  • A. Serosanguineous wound drainage
  • B. Heart rate of 90/min
  • C. Urine output of 30 mL/hr
  • D. Temperature of 37.3°C (99.1°F)
Correct Answer: C

Rationale: A urine output of 30 mL/hr is significantly low and indicates possible renal impairment or inadequate perfusion to the kidneys, which are critical for postoperative recovery. In this situation, decreased urine output could lead to fluid and electrolyte imbalances, affecting the client's overall condition. The nurse should report this finding promptly to the healthcare provider for further evaluation and intervention. Serosanguineous wound drainage is a normal finding in the early postoperative period and does not typically warrant immediate concern. A heart rate of 90/min is within the normal range and may be expected in a postoperative client due to the stress response. A temperature of 37.3°C (99.1°F) is slightly elevated but not a concerning finding in isolation postoperatively.

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A healthcare professional is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

  • A. Postprandial blood glucose
  • B. Glycosylated hemoglobin (HbA1c)
  • C. Glucose tolerance test
  • D. Fasting blood glucose
Correct Answer: B

Rationale: Glycosylated hemoglobin (HbA1c) is the most accurate test for long-term management of blood glucose levels in individuals with diabetes mellitus. HbA1c reflects average blood glucose levels over the past 2-3 months, providing valuable information on the effectiveness of treatment and disease control. Postprandial blood glucose, glucose tolerance test, and fasting blood glucose are essential for monitoring blood glucose levels at specific times but do not offer the same insight into long-term disease management as HbA1c.

A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

  • A. Hypnosis focuses on biofeedback as a relaxation technique
  • B. Hypnosis promotes increased control of pain perception during contractions
  • C. Hypnosis uses therapeutic touch to reduce anxiety during labor
  • D. Hypnosis provides instruction to minimize pain
Correct Answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?

  • A. Bananas
  • B. Fish
  • C. White bread
  • D. Chicken breast
Correct Answer: D

Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.

A healthcare provider is reviewing the laboratory data of a client who is receiving total parenteral nutrition. Which of the following findings should the healthcare provider report?

  • A. Serum calcium 8.5 mg/dL
  • B. Blood glucose level 120 mg/dL
  • C. Serum sodium 138 mEq/L
  • D. Serum albumin 3.5 g/dL
Correct Answer: D

Rationale: The correct answer is D: Serum albumin 3.5 g/dL. A low serum albumin level indicates protein deficiency, which can be a complication of TPN therapy and requires prompt intervention. The other laboratory findings provided (serum calcium 8.5 mg/dL, blood glucose level 120 mg/dL, and serum sodium 138 mEq/L) are within normal ranges and do not specifically indicate complications related to TPN therapy.

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.

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