ATI RN Exit Exam Test Bank

Correct Answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

Correct Answer: A

Rationale: The correct answer is to monitor INR levels for patients on warfarin therapy. INR monitoring is essential because it helps assess the clotting tendency of the blood and ensures that patients are within the therapeutic range to prevent both blood clots and excessive bleeding. Monitoring potassium levels (Choice B), sodium levels (Choice C), or platelet count (Choice D) is not specifically required for patients on warfarin therapy and does not directly impact the effectiveness or safety of the medication.

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.

Correct Answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

Correct Answer: C

Rationale: The correct answer is C: Teach the client pursed-lip breathing technique. Pursed-lip breathing helps clients with COPD improve oxygenation and reduce shortness of breath. Choice A is incorrect because deep breathing and coughing are not recommended every 4 hours for clients with COPD. Choice B is incorrect because a diet high in carbohydrates and low in protein is not specifically indicated for COPD. Choice D is incorrect because fluid restriction is not a standard intervention for COPD unless the client has comorbid conditions that necessitate it.