ATI RN
ATI Exit Exam 2023
1. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?
- A. Flush the tube with 10 mL of water after feeding
- B. Flush the tube with 30 mL of 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: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.
2. While caring for a client with an arterial line, which of the following actions should the nurse take?
- A. Level the transducer with the client's phlebotomy site
- B. Flush the arterial line every 8 hours
- C. Obtain a blood sample for arterial blood gases
- D. Keep the client's hand elevated above the heart level
Correct answer: C
Rationale: Obtaining arterial blood gases is a crucial nursing action when caring for a client with an arterial line. This procedure helps assess the client's oxygenation status and acid-base balance accurately. Leveling the transducer with the client's phlebotomy site (A) is important for accurate pressure measurements, but it is not the primary action in this scenario. Flushing the arterial line every 8 hours (B) is a routine maintenance procedure and not the immediate priority. Keeping the client's hand elevated above the heart level (D) is a good practice to prevent swelling, but it is not directly related to the arterial line care in this case.
3. A nurse is caring for a client who is receiving chemotherapy. The client's platelet count is 25,000/mm3. Which of the following actions should the nurse take?
- A. Administer aspirin for discomfort
- B. Check the client's temperature every 4 hr
- C. Monitor the client's urine output
- D. Check for stool in the client's colostomy bag every 2 hr
Correct answer: B
Rationale: Clients with a low platelet count are at risk of bleeding and infection. Monitoring the client's temperature every 4 hours is crucial to detect early signs of infection, as they may not be able to mount a typical immune response due to their compromised platelet count. Administering aspirin (choice A) is contraindicated in clients with low platelet counts as it can further increase the risk of bleeding. Monitoring urine output (choice C) and checking for stool in a colostomy bag (choice D) are important aspects of care but are not the priority in a client with low platelet count.
4. A client with schizophrenia is experiencing delusions. Which of the following actions should the nurse take?
- A. Encourage the client to discuss the delusions.
- B. Tell the client that the delusions are not real.
- C. Avoid discussing the delusions with the client.
- D. Challenge the client's delusions directly.
Correct answer: B
Rationale: Telling the client that their delusions are not real is the most appropriate action as it helps ground them in reality without reinforcing the delusion. Encouraging the client to discuss the delusions (choice A) may further validate or intensify the delusions. Avoiding discussing the delusions (choice C) may lead to the client feeling isolated and unheard. Challenging the client's delusions directly (choice D) can escalate the situation and cause distress to the client.
5. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group?
- A. The group is organized in an autocratic structure
- B. The group encourages members to focus on a particular issue
- C. The group must be led by a licensed psychiatrist
- D. The group encourages clients to form dependent relationships
Correct answer: B
Rationale: The correct answer is B. Therapeutic groups indeed encourage members to focus on particular issues. This focus helps individuals address specific concerns, work through challenges, and support one another in a structured setting. Choice A is incorrect because therapeutic groups typically promote a democratic structure that values input from all members rather than an autocratic one. Choice C is incorrect as therapeutic groups can be led by various mental health professionals, not solely by licensed psychiatrists. Choice D is incorrect; therapeutic groups aim to foster independent growth and self-reliance rather than promoting dependent relationships.
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