ATI Comprehensive Exit Exam

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A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

  • A. I will need to have my INR checked regularly while taking this medication.
  • B. I should avoid eating leafy green vegetables while taking this medication.
  • C. I will stop taking this medication if I experience nausea.
  • D. I will avoid taking aspirin while taking this medication.
Correct Answer: A

Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.

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A nurse is assessing a school-age child with a urinary tract infection. Which symptom should the nurse expect?

  • A. Periorbital edema.
  • B. Decreased frequency of urination.
  • C. Enuresis.
  • D. Diarrhea.
Correct Answer: C

Rationale: Enuresis is a common symptom of urinary tract infections in school-age children. It is often a presenting symptom due to irritation of the bladder. Periorbital edema (Choice A) is more indicative of conditions like nephrotic syndrome or renal disorders. Decreased frequency of urination (Choice B) is not typically associated with urinary tract infections. Diarrhea (Choice D) is not a common symptom of urinary tract infections but may occur due to other reasons like gastrointestinal infections.

A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

  • A. Take the medication with food to reduce stomach upset.
  • B. Store the medication in a cool, dry place.
  • C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
  • D. This medication may cause drowsiness.
Correct Answer: C

Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.

A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

  • A. Keep calcium gluconate at the bedside.
  • B. Monitor blood pressure every 2 hours.
  • C. Limit IV exposure to light.
  • D. Attach an inline filter to the IV tubing.
Correct Answer: C

Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.

A nurse is reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?

  • A. Heart rate of 80/min
  • B. Blood pressure 130/80 mm Hg
  • C. Weight gain of 2.2 kg (5 lb) in 1 week
  • D. Temperature of 37.2°C (99°F)
Correct Answer: C

Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.

A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?

  • A. Place the client's dentures in a labeled container
  • B. Remove the client's IV lines
  • C. Place the client's body in a semi-fowler's position
  • D. Lower the client's head of the bed
Correct Answer: B

Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.

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