ATI RN
ATI RN Comprehensive Exit Exam
1. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water before each feeding.
- B. Check for gastric residuals every 4 hours.
- C. Elevate the head of the bed to 45 degrees during feedings.
- D. Place the client in the left lateral position during feedings.
Correct answer: C
Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.
2. A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
- A. WBC 4,500/mm3
- B. Hemoglobin 12 g/dL
- C. Platelet count 250,000/mm3
- D. Platelet count 100,000/mm3
Correct answer: D
Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.
3. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct answer: B
Rationale: The correct answer is B: Tachycardia. In acute alcohol withdrawal, tachycardia is a common finding due to increased sympathetic activity. Bradycardia (Choice A) is less likely in this condition since the sympathetic nervous system is typically overactive. Hyperthermia (Choice C) is not a typical finding in acute alcohol withdrawal. Hypotension (Choice D) is less common compared to tachycardia in this situation.
4. A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?
- A. I will need to have my blood work checked regularly while taking clozapine.
- B. I understand that clozapine may cause me to gain weight.
- C. I should report any signs of a fever while taking clozapine.
- D. I should discontinue clozapine once my symptoms improve.
Correct answer: D
Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.
5. What is the best position for a patient with respiratory distress?
- A. Semi-Fowler's position
- B. Trendelenburg position
- C. Prone position
- D. Supine position
Correct answer: A
Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access
ATI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access