ATI RN Comprehensive Exit Exam

Correct Answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

Correct Answer: A

Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.

Correct Answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

Correct Answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

Correct Answer: B

Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.