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 developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?
- A. Administer calcium gluconate at the bedside.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the infusion.
- D. Keep the client on NPO status.
Correct answer: C
Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.
3. During an emergency response following a disaster, which client should be recommended for early discharge?
- A. A client with COPD and a respiratory rate of 44/min.
- B. A client with cancer and a sealed implant for radiation therapy.
- C. A client receiving heparin for deep-vein thrombosis.
- D. A client who is 1 day postoperative following a vertebroplasty.
Correct answer: D
Rationale: The client who is 1 day postoperative following a vertebroplasty is stable and can be discharged early. In an emergency response situation, it is crucial to prioritize clients who are medically stable and do not require immediate hospital care. The client with COPD and a respiratory rate of 44/min needs close monitoring and intervention. The client with cancer and a sealed implant for radiation therapy requires specialized care and follow-up. The client receiving heparin for deep-vein thrombosis needs ongoing anticoagulant therapy and monitoring, making early discharge not appropriate.
4. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?
- A. Drink 2 liters of water per day.
- B. You should restrict your fluid intake to 1 liter per day.
- C. You can drink as much fluid as you want throughout the day.
- D. Limit your fluid intake to 3 liters per day.
Correct answer: B
Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.
5. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?
- A. Hypertension
- B. Bradycardia
- C. Diaphoresis
- D. Piloerection
Correct answer: C
Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.
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