ATI Exit Exam RN

Correct Answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

Correct Answer: A

Rationale: Administering aspirin is the correct initial action when a patient experiences chest pain. Aspirin helps reduce the risk of clot formation and is a standard first-line treatment for chest pain related to possible cardiac issues. Administering nitroglycerin may be appropriate based on the underlying cause of chest pain, but aspirin is typically administered first. Repositioning the patient is not the primary intervention for chest pain, and preparing for surgery is not the immediate action required unless indicated by a healthcare provider after assessment.

Correct Answer: A

Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.

Correct Answer: D

Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.

Correct Answer: A

Rationale: Verifying the patient's identity is a critical step when administering a blood transfusion to ensure that the correct blood product is given to the right patient. This process helps prevent errors and enhances patient safety. Choice B, 'Administer medication,' is incorrect because the focus during a blood transfusion should be on ensuring the correct blood product is administered. Choice C, 'Monitor vital signs,' is also important but comes after verifying the patient's identity. Choice D, 'Start blood transfusion without verification,' is incorrect and unsafe as patient identification verification is essential prior to starting any medical procedure, especially one as important as a blood transfusion.