ATI RN
ATI Comprehensive Exit Exam 2023
1. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?
- A. Flush the tube with 30 mL of water after feeding
- B. Flush the tube with 10 mL of sterile water before feeding
- C. Place the client in a left lateral position
- D. Place the feeding bag 61 cm (24 in) above the client's abdomen
Correct answer: B
Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.
2. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Apply a sterile dressing.
- B. Suction the tracheostomy.
- C. Remove the inner cannula.
- D. Clean the stoma with sterile saline.
Correct answer: B
Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.
3. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?
- A. Maternal fever.
- B. Fetal anemia.
- C. Maternal hypoglycemia.
- D. Chorioamnionitis.
Correct answer: C
Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.
4. A healthcare provider is planning care for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the healthcare provider include?
- A. Administer 0.9% sodium chloride with the TPN.
- B. Change the TPN tubing every 24 hours.
- C. Weigh the client every 72 hours.
- D. Flush the TPN line with heparin.
Correct answer: B
Rationale: The correct action the healthcare provider should include is changing the TPN tubing every 24 hours to decrease the risk of infection. Administering 0.9% sodium chloride with TPN is not typically recommended as it can cause chemical instability. Weighing the client every 72 hours is important but not directly related to TPN administration. Flushing the TPN line with heparin is not a standard practice and not recommended as it can increase the risk of complications.
5. A nurse is assessing a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 62/min
- B. Blood pressure of 118/78 mm Hg
- C. Respiratory rate of 10/min
- D. Pain rating of 4 on a scale of 0 to 10
Correct answer: C
Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.
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