ATI RN
ATI RN Exit Exam Test Bank
1. While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?
- A. Monitor the client's urinary output.
- B. Check the client's blood pressure.
- C. Assess the client for constipation.
- D. Monitor the client's respiratory rate.
Correct answer: D
Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.
2. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?
- A. Elevate the head of the bed 45 degrees during feedings.
- B. Place the client in the left lateral position for 30 minutes after feedings.
- C. Flush the tube with 30 mL of sterile water before each feeding.
- D. Check gastric residuals every 8 hours.
Correct answer: A
Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.
3. A nurse is teaching a client about the physiological changes that occur with aging. Which of the following findings should the nurse expect?
- A. Decreased sense of taste
- B. Decreased blood pressure
- C. Increased gastric secretions
- D. Increased accommodation to near vision
Correct answer: A
Rationale: The correct answer is A: Decreased sense of taste. As individuals age, they may experience a decrease in their sense of taste due to changes in taste buds and a decrease in saliva production. This can lead to a reduced ability to taste flavors or distinguish between different tastes. Choices B, C, and D are incorrect. Decreased blood pressure is not a consistent physiological change with aging; instead, blood pressure may increase or remain stable. Gastric secretions tend to decrease with age, leading to issues like decreased absorption of certain nutrients. Accommodation to near vision typically decreases with age, causing a condition known as presbyopia, where individuals have difficulty focusing on close objects.
4. What is the best intervention for a patient with respiratory distress?
- A. Administer oxygen
- B. Reposition the patient
- C. Provide bronchodilators
- D. Provide humidified air
Correct answer: A
Rationale: Administering oxygen is the best intervention for a patient with respiratory distress because it helps improve oxygenation levels and alleviates respiratory distress directly. Providing oxygen addresses the primary issue of inadequate oxygen supply, which is crucial in managing respiratory distress. Repositioning the patient, while important for airway clearance, may not address the immediate need for oxygen. Providing bronchodilators and humidified air can be beneficial in certain respiratory conditions, but when a patient is in respiratory distress, ensuring adequate oxygenation through oxygen administration takes precedence.
5. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?
- A. Administer nitroglycerin sublingually.
- B. Administer 2L of oxygen via nasal cannula.
- C. Administer aspirin 325 mg orally.
- D. Obtain a 12-lead ECG.
Correct answer: D
Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.
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