ATI Exit Exam ( ATI Comprehensive Predictor)

Correct Answer:

A. Consult the pharmacist about potential interactions between the client's regular medications and warfarin.

Explanation:

Warfarin has numerous drug and food interactions that can either increase bleeding risk or reduce its effectiveness. The nurse should consult the pharmacist to evaluate potential interactions with the client’s existing medications, ensuring safe discharge and effective anticoagulation management.

Why Other Options Are Incorrect:

B. Tell the client they can continue to drink cranberry juice while taking warfarin.

Cranberry juice can increase the effects of warfarin and raise the risk of bleeding. Clients should avoid or limit cranberry products unless otherwise advised by the provider.

C. Recommend the client take warfarin at the same time as other medications.

Warfarin should be taken consistently at the same time each day, but not necessarily with other medications, especially without assessing for potential interactions.

D. Advise the client that over-the-counter medications remain safe to consume as needed.

This is incorrect and unsafe. Many OTC medications, especially NSAIDs like ibuprofen, can increase the risk of bleeding when taken with warfarin. All OTC drug use should be reviewed with a provider or pharmacist.

Correct Answers:

A. "Attempt to void every 2 hours."

B. "Perform Kegel exercises several times daily."

D. "Take prescribed diuretics no later than 2000."

E. "Maintain optimal body weight for height."

Explanation:

A. "Attempt to void every 2 hours."

Scheduled voiding can help prevent accidents by emptying the bladder regularly before stress triggers like sneezing or lifting occur.

B. "Perform Kegel exercises several times daily."

Kegel exercises strengthen the pelvic floor muscles, which can help control urine leakage associated with stress incontinence.

D. "Take prescribed diuretics no later than 2000."

Taking diuretics earlier in the day helps reduce the need to urinate at night and avoids contributing to incontinence episodes during rest or sleep.

E. "Maintain optimal body weight for height."

Excess weight increases intra-abdominal pressure, which can worsen stress incontinence. Maintaining a healthy weight can reduce symptoms.

Why Other Option Is Incorrect:

C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day."

This fluid intake is too low and could lead to dehydration or concentrated urine, which can irritate the bladder. Clients should maintain adequate hydration (typically 1,500–2,000 mL/day) unless otherwise instructed by a provider.

Correct Answer:

B. Maintain the irrigation solution rate.

Explanation:

B. Maintain the irrigation solution rate.

Pink-tinged urine is an expected finding in the early postoperative period following a transurethral resection of the prostate (TURP). It indicates mild bleeding, which is common after the procedure. The nurse should maintain the current irrigation rate to help prevent clot formation and keep the urine light pink or clear.

Why Other Options Are Wrong:

A. Perform the Credés maneuver.

The Credés maneuver, which involves manual bladder compression, is not appropriate in this situation and is not used for clients with continuous bladder irrigation or recent prostate surgery due to the risk of trauma or increased bleeding.

C. Replace the indwelling urinary catheter.

There is no indication that the catheter is malfunctioning or obstructed. Pink-tinged urine is expected; therefore, replacing the catheter is unnecessary and could increase the risk of infection or trauma.

D. Warm the irrigation solution.

While warming irrigation solutions may help reduce bladder spasms in some cases, it is not a standard or necessary action in response to pink-tinged urine. The focus should remain on maintaining proper irrigation to ensure continuous drainage.

Correct Answer C: I will have an identification band that matches the one my baby wears.

Explanation:

Hospitals use matching identification bands for mother and newborn to ensure security and prevent infant abduction or mix-ups. This system helps staff verify that the baby is with the correct parent at all times.

Why the Other Options Are Incorrect:

A . I will carry my baby to the nursery.

Generally, mothers are encouraged to keep their babies in their rooms (rooming-in) rather than carrying them to the nursery for security and bonding reasons. If the baby must go to the nursery, proper staff protocols and security measures apply.

B. I can take my baby to the lobby to visit family.

Newborns typically are not taken to public areas like the lobby to reduce infection risk and enhance security. Visitors usually come to the mother’s room instead.

D. I can remove my security band to give it to a family member.

Security bands should never be removed or given to anyone else. Removing the band compromises security and identification measures designed to protect the baby.

Summary:

The correct answer is C. This demonstrates that the mother understands the importance of matching identification bands for newborn security.

Correct Answer:

B. Black cohosh

Explanation:

B. Black cohosh

Black cohosh is commonly used to relieve menopausal symptoms. However, it can lower blood pressure through its vasodilatory effects. When combined with anesthesia, it can lead to significant intraoperative hypotension, making it a safety concern before surgery.

Why Other Options Are Wrong:

A. Probiotics

Probiotics are live microorganisms that promote gut and immune health. They do not have an effect on blood pressure or anesthesia and are not associated with increased surgical risk.

C. Soy

Soy contains plant-based estrogens and is often used for heart and menopausal health. While it may affect hormone levels, it does not significantly influence blood pressure in a way that would pose a risk during surgery.

D. Flaxseed

Flaxseed is rich in fiber and omega-3 fatty acids and may mildly lower blood pressure. However, its effect is minimal and not considered a surgical risk when compared to black cohosh.

Correct Answer:

C. Monitor the client's temperature every 2 hr.

Explanation:

When a client experiences spontaneous rupture of membranes (SROM) at 36 weeks, there is an increased risk of infection (chorioamnionitis). The nurse should monitor the client's temperature every 2 hours to detect early signs of infection, which is critical to ensure maternal and fetal well-being.

Why Other Options Are Incorrect:

A. Administer magnesium sulfate to the client

Magnesium sulfate is typically used for neuroprotection before 32 weeks gestation or for seizure prophylaxis in preeclampsia, not routinely at 36 weeks following SROM.

B. Administer betamethasone to the client

Betamethasone is given to enhance fetal lung maturity, usually between 24 and 34 weeks gestation. At 36 weeks, the lungs are likely mature, and the benefit is less clear.

D. Monitor fetal heart rate every 4 hr

Fetal heart rate should be monitored more frequently, especially after SROM, due to the risk of umbilical cord prolapse or fetal distress. Every 4 hours is too infrequent in this setting.

Correct Answer: Check the client's gag reflex

Detailed Explanation of the Correct Answer:

 Check the client's gag reflex

This is the first and most important nursing action following a bronchoscopy. During the procedure, a local anesthetic is typically used to numb the throat, suppressing the gag reflex. Before giving the client anything by mouth (such as water or food), the nurse must assess for the return of the gag reflex to prevent aspiration, making this the top priority under the ABC (Airway, Breathing, Circulation) framework.

Why the Other Options Are Incorrect:

Inform the client they might experience a low-grade fever

This is appropriate patient education and might be done later, but it is not the first priority after the procedure. Airway safety must come before education.

 Provide the client with sips of water

This should not be done until the gag reflex has returned. Giving fluids prematurely can lead to choking or aspiration pneumonia.

Instruct the client to report bleeding

While this is important and relevant, it is not the first action. Bleeding is a potential complication, but the immediate concern is airway safety.

Summary:

The first action after a bronchoscopy is to Check the client's gag reflex to ensure the client can safely swallow. All other actions are appropriate after confirming this critical reflex has returned.

Correct Answer:

A. Weigh the client before and after the procedure.

Explanation:

A. Weigh the client before and after the procedure

Paracentesis involves removing fluid from the peritoneal cavity, often to relieve discomfort from ascites. Weighing the client before and after helps determine the amount of fluid removed and evaluates effectiveness of the procedure.

Why Other Options Are Incorrect:

B. Administer a low-volume hypertonic enema the night before the procedure

This is not necessary for a paracentesis. Enemas are used for bowel procedures, not for draining ascitic fluid.

C. Place the client in a side-lying position for the procedure

The correct position for paracentesis is usually upright (high Fowler's or sitting) to allow the fluid to pool in the lower abdomen, making it easier to access and drain.

D. Ensure the client has a full bladder just prior to the procedure

This is incorrect. The bladder should be emptied prior to paracentesis to reduce the risk of bladder injury during needle insertion.

Correct Answer:

C. Substernal retractions

Explanation:

C. Substernal retractions

Substernal retractions are a sign of respiratory distress and can indicate the onset of acute chest syndrome (ACS) in clients with sickle-cell anemia. ACS is a life-threatening complication characterized by chest pain, fever, cough, hypoxia, and pulmonary infiltrates. Retractions suggest increased work of breathing and impaired oxygenation, requiring immediate medical evaluation and intervention.

Why Other Options Are Incorrect:

A. Hematuria

While hematuria can occur in sickle-cell disease due to renal involvement, it is not specific to acute chest syndrome and is not an immediate emergency.

B. Sneezing

Sneezing is typically associated with upper respiratory infections or allergies and is not a manifestation of ACS. It does not require urgent intervention.

D. Temperature 37.9°C (100.2° F)

This is a low-grade fever and could be an early sign of infection but, by itself, does not indicate ACS. However, fever accompanied by respiratory symptoms would be more concerning.