ATI RN
ATI Comprehensive Exit Exam 2023 With NGN Quizlet
1. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?
- A. Elevate the head of the bed to 15 degrees
- B. Check gastric residual volumes every 6 hours
- C. Monitor the pH of gastric aspirate
- D. Instill 10 mL of air into the tube before feeding
Correct answer: B
Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.
2. A client is experiencing mild anxiety. Which of the following findings should the nurse expect?
- A. Feelings of dread
- B. Heightened perceptual field
- C. Rapid speech
- D. Purposeless activity
Correct answer: B
Rationale: In clients experiencing mild anxiety, a heightened perceptual field is a common finding. This means that the individual may be more alert and observant of their surroundings, sometimes to the point of being hyper-aware. Choices A, C, and D are less likely to be associated with mild anxiety. Feelings of dread (Choice A) are more commonly seen in moderate to severe anxiety. Rapid speech (Choice C) may be observed in some cases of anxiety, but it is not a specific hallmark of mild anxiety. Purposeless activity (Choice D) is more indicative of severe anxiety or other mental health conditions.
3. A nurse is reviewing the medical record of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct answer: C
Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased risk of bleeding. Stool softeners help prevent straining during bowel movements, which can reduce the risk of bleeding in individuals with thrombocytopenia. Encouraging the client to floss daily (Choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is more about reducing the risk of infection rather than managing thrombocytopenia.
4. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Insert a tongue depressor into the client's mouth.
- B. Restrain the client's arms and legs.
- C. Turn the client onto their side.
- D. Place the client in a prone position.
Correct answer: C
Rationale: During a tonic-clonic seizure, the nurse should turn the client onto their side. This action helps maintain an open airway by allowing saliva or any vomitus to drain out of the mouth, reducing the risk of aspiration. Inserting a tongue depressor (choice A) is incorrect as it can cause injury to the client's mouth and is not recommended during a seizure. Restraining the client's arms and legs (choice B) can lead to physical harm and should be avoided. Placing the client in a prone position (choice D) is dangerous as it can obstruct the airway and hinder breathing, which is not suitable for a client experiencing a seizure.
5. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?
- A. Allow the child to handle the IV supplies to become familiar with them.
- B. Tell the child they will feel discomfort during the catheter insertion.
- C. Use a mummy restraint to hold the child during the catheter insertion.
- D. Require the parents to leave the room during the procedure.
Correct answer: B
Rationale: The correct answer is B because informing the child that they will feel discomfort during catheter insertion is crucial to prepare them for the procedure. Choice A is incorrect as children should not handle medical supplies. Choice C is inappropriate as using a restraint can cause anxiety and fear in the child. Choice D is not necessary as having parents present can provide comfort and support to the child during the procedure.
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