ATI RN Comprehensive Exit Exam

Correct Answer: A

Rationale: The correct initial action for a patient with chest pain is to administer oxygen. Chest pain can be caused by insufficient oxygenation, and providing oxygen helps alleviate the pain by increasing oxygen levels in the blood. Administering nitroglycerin or morphine may be appropriate based on the underlying cause of the chest pain, but oxygen should be given first to ensure the patient's oxygen supply is adequate. Surgery is not typically the initial intervention for chest pain.

Correct Answer: A

Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.

Correct Answer: C

Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.

Correct Answer: A

Rationale: Administering diuretics is the best method to manage fluid overload in a patient with heart failure. Diuretics help to remove excess fluid from the body by increasing urine output, thus reducing the fluid volume in the bloodstream and tissues. Providing oral fluids (choice B) or increasing fluid intake (choice C) would exacerbate the fluid overload rather than managing it. Chest physiotherapy (choice D) is not indicated for managing fluid overload in heart failure; it is more commonly used for conditions affecting the lungs or airways.

Correct Answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.