ATI RN
ATI Exit Exam 2024
1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
- A. Vomiting.
- B. Hypertension.
- C. Epigastric pain.
- D. Contractions.
Correct answer: D
Rationale: Following an amniocentesis at 33 weeks of gestation, the nurse should monitor the client for contractions. Contractions can indicate preterm labor, which requires immediate attention. Vomiting, hypertension, and epigastric pain are not typically associated with amniocentesis complications at this gestational age.
2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 48 hours.
- B. Change the TPN tubing every 24 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Monitor the client's weight every 72 hours.
Correct answer: B
Rationale: The correct answer is to change the TPN tubing every 24 hours. This action helps reduce the risk of infection because the high glucose content of TPN promotes bacterial growth. Choice A is incorrect as changing the tubing every 48 hours would not provide adequate infection prevention. Option C, monitoring urine output, is important for assessing renal function but is not directly related to preventing TPN-related infections. Option D, monitoring weight, is essential for assessing nutritional status but does not directly address infection prevention in TPN administration.
3. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?
- A. Flush the tube with 10 mL of water after feeding
- B. Flush the tube with 30 mL of 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: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.
4. A client with a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear shoes that are one size larger than your normal size.
- C. Wear cotton socks to keep your feet dry.
- D. Trim your toenails straight across.
Correct answer: D
Rationale: The correct answer is D: "Trim your toenails straight across." This instruction is essential to prevent ingrown toenails in clients with diabetes. Soaking feet in warm water daily (choice A) may increase the risk of skin breakdown and infection. Wearing shoes one size larger than normal (choice B) can lead to friction and cause blisters. While wearing cotton socks (choice C) is generally recommended, the emphasis should be on moisture-wicking materials rather than just cotton.
5. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?
- A. Dry mucous membranes
- B. Polyuria
- C. Epistaxis
- D. Diarrhea
Correct answer: C
Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.
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