ATI RN Exit Exam Test Bank

Correct Answer: C

Rationale: The correct answer is C because a urine output of 30 mL/hr indicates oliguria, which can be a sign of dehydration or kidney impairment postoperatively. This finding should be reported to the provider for further evaluation. Choices A, B, and D are within normal parameters for a client who is 2 days postoperative following abdominal surgery and do not raise immediate concerns. Serosanguineous drainage on the dressing is an expected finding in the early postoperative period, a heart rate of 88/min is within the normal range, and a blood pressure of 110/70 mm Hg is also within normal limits.

Correct Answer: D

Rationale: The correct answer is D because a blood glucose level of 120 mg/dL falls within the normal range. A low serum albumin level, as mentioned in choice B, should be reported as it may indicate malnutrition. Choices A and C are within normal ranges and would not typically require immediate reporting.

Correct Answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.

Correct Answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

Correct Answer: B

Rationale: Digoxin is commonly prescribed to manage atrial fibrillation by controlling heart rate. While Warfarin is used to prevent blood clots, it is not primarily used for controlling heart rate in atrial fibrillation. Aspirin is not the first-line treatment for atrial fibrillation and is generally not recommended for rhythm control. Lisinopril is an ACE inhibitor used to treat high blood pressure and heart failure, but it is not typically prescribed as the primary medication for managing atrial fibrillation.