ATI RN
ATI Comprehensive Exit Exam 2023 With NGN Quizlet
1. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?
- A. Keep the head of the bed elevated to 15 degrees.
- B. Change the feeding bag every 48 hours.
- C. Administer the feeding through a large-bore syringe.
- D. Flush the tube with 0.9% sodium chloride every 4 hours.
Correct answer: D
Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.
2. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
- A. Request a renewal of the prescription every 8 hours.
- B. Check the client's peripheral pulse rate every 30 minutes.
- C. Obtain a prescription for restraint within 4 hours.
- D. Document the client's condition every 15 minutes.
Correct answer: C
Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.
3. A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Clamp the chest tube for 15 minutes every 2 hours.
- B. Empty the drainage collection chamber when it is half full.
- C. Keep the drainage system below the level of the client's chest.
- D. Strip the chest tube every 2 hours to maintain patency.
Correct answer: C
Rationale: The correct action the nurse should take when caring for a client with a chest tube is to keep the drainage system below the level of the client's chest. This positioning helps prevent fluid from flowing back into the pleural space, ensuring proper drainage and effective functioning of the chest tube. Clamping the chest tube intermittently or stripping it frequently can lead to complications and should be avoided. Emptying the drainage collection chamber at specific intervals may vary based on institutional protocols, but it should be done when it is no more than two-thirds full to prevent backflow and maintain accurate monitoring of drainage output.
4. A school nurse is teaching a parent about absence seizures. What information should be included?
- A. This type of seizure lasts 30 to 60 seconds.
- B. This type of seizure can be mistaken for daydreaming.
- C. The child usually has an aura prior to onset.
- D. This type of seizure has a gradual onset.
Correct answer: B
Rationale: The correct answer is B because absence seizures are brief and can be mistaken for daydreaming. Choice A is incorrect because absence seizures typically last a few seconds, not 30 to 60 seconds. Choice C is incorrect as absence seizures usually occur suddenly without an aura. Choice D is incorrect because absence seizures have a sudden onset, not a gradual one.
5. 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.
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