ATI RN Exit Exam

Correct Answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

Correct Answer: C

Rationale: The correct answer is C, respiratory depression. When a patient is receiving morphine, respiratory depression is the most concerning side effect because it can lead to serious complications, including respiratory arrest and even death. Monitoring the patient's respiratory status is crucial to ensure early detection of any signs of respiratory depression. Choices A, B, and D are incorrect because although hypotension, bradycardia, and hypertension can occur as side effects of morphine, they are not as immediately life-threatening as respiratory depression in this context.

Correct Answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

Correct Answer: A

Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.

Correct Answer: A

Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.