ATI EXIT EXAM Graded A+

ATI EXIT EXAM 2022/2023 Graded A+ A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take?

• (Unable to read)
• Tell the child they will feel discomfort during the catheter insertion.
• Use a mummy restraint to hold the child during the catheter insertion.
• Require the parents to leave the room during the procedure. - ANSWER B. Tell the

child they will feel discomfort during the catheter insertion.A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching?

• "I will soak in the tub rather and showering"
• "I will wear loose clothing around my ICD"
• "I will stop using my microwave oven at home because of my ICD"
• "I can hold my cellphone on the same side of my body as the ICD" - ANSWER B. "I

will wear loose clothing around my ICD" A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?

• "Describe your feelings to me about being pregnant"
• "You should discuss your feelings about being pregnant with your provider"
• "Have you discussed these feelings with your partner?"
• "When did you start having these feelings?" - ANSWER A. "Describe your feelings to

me about being pregnant" A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

• Below-the knee amputation
• Fractured tibia
• 95% full-thickness body burn
• 10cm (4in) laceration to the forearm - ANSWER A. Below-the knee amputation

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?

• Remove the client's restraint every 4hr
• Document the client's condition every 15 min
• Attach the restrain to the bed's side rails

• Request a PRN restrain prescription for clients who are aggressive - ANSWER B.

Document the client's condition every 15 min A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?

• Chlamydia
• Human papillomavirus
• Candidiasis
• Herps simplex virus - ANSWER A. Chlamydia

A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of no blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

• Place the client upright on a donut-shaped cushion
• Teach the client to shift his weight every 15 min while sitting
• Turn and reposition the client every 3 hr while in bed
• Assess pressure points every - ANSWER B. Teach the client to shift his weight every

15 min while sitting A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC).Which of the following information should the charge nurse include?

• "The proxy should make health care decisions for the client regardless of the client's

ability to do so."

• "The proxy can make financial decisions if the need arises."
• "The proxy can make treatment decisions if the client is under anesthesia."
• "The proxy should manage legal issues for the client." - ANSWER C. "The proxy can

make treatment decisions if the client is under anesthesia." A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management (Unable to read) a safe option for the client?

• Naloxone hydrochloride.
• Spinal anesthesia.
• Pudendal block.
• Butorphanol tartrate - ANSWER C. Pudendal block.

A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian

• A client who has a prescription for warfarin and states "I will need to limit how much

spinach I eat".

• A client who has gout and states, "I can continue to eat anchovies on my pizza."
• A client who has a prescription for spironolactone and states "I will reduce my intake

of foods that contain potassium".

• A client who has (Unable to read) and states "I'll plan to take my calcium carbonate

with a full glass of water" - ANSWER B. A client who has gout and states, "I can continue to eat anchovies on my pizza." A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications?

• Methylprednisolone.
• Ondansetron.
• Guaifenesin.
• Amoxicillin - ANSWER A. Methylprednisolone.

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider?Exhibit 1

Blood pressure: 102/56 mm Hg.

Heart rate: 95/min

Respiratory rate: 18/min

Temperature: 37.4C (99.3F)

Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors.Exhibit 3 Nurse's notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous.

• Dietary intake
• Heart rate.
• Sore throat.
• Blood pressure - ANSWER C. Sore throat.

A nurse is planning care for a client who has bipolar disorder and is experiencing mania.Which of the following interventions should the nurse include in the plan?

• Encourage the client to spend time in the day room
• Withdraw the client's TV privileges is the does not attend group therapy
• Encourage the client to take frequent rest periods

• Place the client in seclusion when he exhibits signs of anxiety - ANSWER C.

Encourage the client to take frequent rest periods A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

• "Does the doctor know you are eating that?"
• "Why are you eating seaweed soup?"
• "Of course, I will heat that up for you"
• "The hospital good is more nutritious" - ANSWER C. "Of course, I will heat that up for

you" A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?

• Leaving a nasogastric tube clamped after administering oral medication
• Documenting communication with a provider in the progress notes of the client's

medical records

• Administering potassium via IV bolus
• Placing a yellow bracelet on a client who is at risk for falls - ANSWER C.

Administering potassium via IV bolus A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

• Placing a belt restraint on a school-age child who has seizures.
• Securing wrist restraints to the bed rails for an adolescent.
• Applying elbow immobilizers of an infant receiving cleft lip injury
• Keeping the side rails of a toddler's crib elevated. - ANSWER C. Applying elbow

immobilizers of an infant receiving cleft lip injury A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster.Which of the following information should the nurse include?

• Children who have varicella are contagious until vesicles are crusted.
• Children who have varicella should receive the herpes zoster vaccination.
• Children who have varicella should be placed in droplet precaution.
• Children who have varicella are contagious 4 days before the first vesicle eruption. -

ANSWER A. Children who have varicella are contagious until vesicles are crusted.A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following requires intervention by the staff nurse?

• Waits 2 minutes between suctions.
• Encourages the client to cough during suctioning.