ATI RN Exit Exam Test Bank

Correct Answer: B

Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.

Correct Answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

Correct Answer: A

Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.

Correct Answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

Correct Answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.