ATI RN
ATI Exit Exam 2024
1. A client is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?
- A. A history of gastroesophageal reflux disease.
- B. Receiving a high-osmolarity formula.
- C. Sitting in a high-Fowler's position during the feeding.
- D. A residual of 65 mL 1 hr post-feeding.
Correct answer: A
Rationale: The correct answer is A. Clients with a history of gastroesophageal reflux disease are at risk for aspiration due to the potential of regurgitation, which can lead to aspiration of stomach contents into the lungs. Choice B (receiving a high-osmolarity formula) can lead to issues like diarrhea or dehydration but is not directly related to aspiration. Choice C (sitting in a high-Fowler's position during the feeding) is actually a preventive measure to reduce the risk of aspiration. Choice D (a residual of 65 mL 1 hr post-feeding) is a concern for delayed gastric emptying but not a direct risk factor for aspiration.
2. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Blood pressure of 130/85 mm Hg
- C. Coughing up small amounts of sputum
- D. Absent gag reflex
Correct answer: D
Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.
3. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?
- A. Offer fluids every 2 hours.
- B. Document the client's behavior prior to being placed in seclusion.
- C. Discuss with the client their inappropriate behavior prior to seclusion.
- D. Assess the client's behavior every hour.
Correct answer: B
Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.
4. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following actions should the nurse take?
- A. Administer naloxone
- B. Administer diazepam
- C. Encourage oral fluid intake
- D. Administer magnesium sulfate
Correct answer: B
Rationale: The correct action for the nurse to take when caring for a client with alcohol use disorder experiencing withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to manage withdrawal symptoms in these clients by reducing anxiety, tremors, and the risk of seizures. Administering naloxone (Choice A) is used for opioid overdose, not alcohol withdrawal. Encouraging oral fluid intake (Choice C) is generally beneficial but not a specific intervention for alcohol withdrawal. Administering magnesium sulfate (Choice D) is not indicated for alcohol withdrawal but may be used for other conditions like preeclampsia or eclampsia.
5. A nurse is caring for a client who is 1 day postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?
- A. Keep the residual limb flat on the bed
- B. Elevate the residual limb on a pillow
- C. Place the client in a prone position for 30 minutes 4 times a day
- D. Keep the residual limb dependent
Correct answer: C
Rationale: The correct action the nurse should take is to place the client in a prone position for 30 minutes four times a day. This position helps prevent contractures after an amputation by stretching the hip flexors and preventing shortening of the residual limb. Keeping the residual limb flat on the bed (Choice A) may lead to contractures. Elevating the residual limb on a pillow (Choice B) can also cause contractures and hinder proper healing. Keeping the residual limb dependent (Choice D) is not recommended as it does not promote proper positioning and circulation.
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