ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?
- A. Administer the injection into the muscle of your thigh.
- B. Pinch the skin before inserting the needle.
- C. Rub the injection site after administering the medication.
- D. Administer the injection into the fat tissue of your abdomen.
Correct answer: D
Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.
2. A client with thrombocytopenia is receiving care from a nurse. Which of the following actions should the nurse include?
- 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 the client raw vegetables.
Correct answer: C
Rationale: In a client with thrombocytopenia, the platelet count is low, leading to a risk of bleeding. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can reduce the risk of bleeding episodes. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is related to infection control but does not address the specific risk of bleeding in thrombocytopenia. Avoiding serving the client raw vegetables (Choice D) is important in clients with neutropenia to prevent infections, not in thrombocytopenia.
3. A nurse is providing dietary teaching to a client who has cholecystitis. Which of the following foods should the nurse instruct the client to avoid?
- A. Bananas.
- B. Oatmeal.
- C. Brown rice.
- D. Whole milk.
Correct answer: D
Rationale: The correct answer is D: Whole milk. Clients with cholecystitis should avoid high-fat foods, and whole milk contains high levels of fat. Bananas, oatmeal, and brown rice are generally considered safe for clients with cholecystitis as they are low in fat and easily digestible. Bananas are a good source of potassium, oatmeal is high in fiber, and brown rice provides complex carbohydrates. Therefore, the nurse should advise the client to avoid whole milk but can recommend the other choices as part of a balanced diet for cholecystitis.
4. A nurse is reviewing the laboratory values of a client who has liver cirrhosis. Which of the following findings should the nurse report to the provider?
- A. Bilirubin 0.8 mg/dL
- B. Ammonia 35 mcg/dL
- C. Prothrombin time 16 seconds
- D. Albumin 4 g/dL
Correct answer: C
Rationale: In clients with liver cirrhosis, an elevated prothrombin time indicates impaired liver function and decreased production of clotting factors. This finding should be reported to the provider for further evaluation and management. Choices A, B, and D are within normal ranges and do not specifically indicate worsening liver cirrhosis. Bilirubin 0.8 mg/dL is normal, ammonia 35 mcg/dL is within the reference range, and albumin 4 g/dL is also within the normal range for this client population.
5. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?
- A. Check for the presence of bowel sounds every 8 hours.
- B. Flush the NG tube every 24 hours.
- C. Provide the client with sips of water every 2 hours.
- D. Keep the client's head of the bed elevated to 45 degrees.
Correct answer: D
Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.
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