ATI RN Exit Exam Test Bank

Correct Answer: A

Rationale: The correct answer is to monitor the patient's respiratory rate. This assessment is essential as it ensures that the patient is breathing adequately post-surgery. Maintaining a patent airway and adequate oxygenation are the top priorities in the immediate postoperative period. Monitoring blood pressure, checking the surgical site, or monitoring heart rate are important assessments but are not the priority immediately upon the patient's return from surgery.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is crucial in managing patients with suspected DVT as it helps prevent further clot formation and reduces the risk of complications like pulmonary embolism. Choice B, applying compression stockings, is more focused on preventing DVT in high-risk patients rather than managing an established case. Encouraging ambulation, choice C, is beneficial in the prevention of DVT but is not the primary management for suspected cases. Monitoring oxygen saturation, choice D, is important in overall patient care but is not the primary intervention for suspected DVT.

Correct Answer: B

Rationale: The most appropriate nursing intervention for a patient experiencing hypoglycemia is to administer oral glucose. Oral glucose is usually sufficient for treating mild hypoglycemia and can be administered quickly and easily. Administering IV glucose (Choice A) is reserved for severe cases where the patient is unable to swallow or unconscious. Checking blood sugar in 15 minutes (Choice C) is important but providing glucose should come first. Providing a high-calorie snack (Choice D) may not be as rapidly effective as administering oral glucose in quickly raising blood sugar levels in a patient experiencing hypoglycemia.

Correct Answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

Correct Answer: D

Rationale: Corrected Rationale: Early decelerations are caused by head compression resulting from the fetal head being compressed during contractions. They are considered benign and do not indicate fetal distress. Choice A, fetal hypoxia, is incorrect because early decelerations are not associated with fetal hypoxia. Choice B, abruptio placentae, is incorrect as it is a condition where the placenta prematurely separates from the uterine wall. Choice C, post maturity, is incorrect as it refers to a fetus that remains in the uterus past the due date.