ATI Exit Exam 180 Questions Quizlet

Correct Answer: B

Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.

Correct Answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.

Correct Answer: D

Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.

Correct Answer: D

Rationale: The correct answer is D. Black, tarry stools can indicate gastrointestinal bleeding, a serious adverse effect of warfarin that requires immediate medical attention. Option A is incorrect because while bruising is a common side effect of warfarin, it is not limited to the elbows. Option B is incorrect as a red rash is not a typical adverse effect of warfarin. Option C is also incorrect because developing a cough is not a reason to discontinue warfarin unless advised by a healthcare provider.

Correct Answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.