ATI RN
ATI Exit Exam 2023
1. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?
- A. Provide reality orientation throughout the day.
- B. Limit the client's choices to prevent decision fatigue.
- C. Encourage the client to participate in group therapy.
- D. Engage the client in sensory stimulation activities.
Correct answer: A
Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.
2. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my vision checked regularly while taking this medication.
- B. This medication can cause my urine to turn reddish-orange.
- C. I need to wear sunscreen and protective clothing while taking this medication.
- D. I will discontinue this medication if I experience nausea.
Correct answer: B
Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.
3. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30 degrees.
- B. Check gastric residual volumes every 4 hours.
- C. Administer the feeding at room temperature.
- D. Flush the feeding tube with 20 mL of water every 8 hours.
Correct answer: B
Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.
4. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy?
- A. Varicella vaccine.
- B. Inactivated polio vaccine.
- C. Tetanus diphtheria and acellular pertussis vaccine.
- D. Inactivated influenza vaccine.
Correct answer: C
Rationale: The correct answer is C: Tetanus diphtheria and acellular pertussis (Tdap) vaccine. The Tdap vaccine can be safely administered during pregnancy to protect both the mother and the newborn against whooping cough. Choices A, B, and D are incorrect because the Varicella vaccine, Inactivated polio vaccine, and Inactivated influenza vaccine are generally not recommended during pregnancy due to safety concerns.
5. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?
- A. Sodium 144 mEq/L
- B. Potassium 5.2 mEq/L
- C. Bicarbonate 24 mEq/L
- D. Magnesium 1.9 mEq/L
Correct answer: B
Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.
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