ATI RN
ATI Exit Exam 2024
1. A client who has a new prescription for lithium is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have my blood levels checked regularly while taking this medication.
- B. I should take this medication on an empty stomach.
- C. I should avoid eating foods that are high in sodium.
- D. I should stop taking this medication if I experience nausea.
Correct answer: A
Rationale: The correct answer is A. Clients prescribed lithium need regular monitoring of blood levels to ensure the medication's effectiveness and safety. This monitoring helps to keep the medication within the therapeutic range and prevent toxicity. Choice B is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Choice C is not directly related to lithium therapy; however, excessive sodium intake can affect lithium levels. Choice D is incorrect as abruptly stopping lithium can lead to adverse effects and should only be done under healthcare provider guidance.
2. A client is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?
- A. A history of gastroesophageal reflux disease.
- B. Receiving a high-osmolarity formula.
- C. Sitting in a high-Fowler's position during the feeding.
- D. A residual of 65 mL 1 hr post-feeding.
Correct answer: A
Rationale: The correct answer is A. Clients with a history of gastroesophageal reflux disease are at risk for aspiration due to the potential of regurgitation, which can lead to aspiration of stomach contents into the lungs. Choice B (receiving a high-osmolarity formula) can lead to issues like diarrhea or dehydration but is not directly related to aspiration. Choice C (sitting in a high-Fowler's position during the feeding) is actually a preventive measure to reduce the risk of aspiration. Choice D (a residual of 65 mL 1 hr post-feeding) is a concern for delayed gastric emptying but not a direct risk factor for aspiration.
3. 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: Obtaining a prescription for restraint within 4 hours is the correct action when managing restraints in a client with acute mania. This timeframe ensures that the use of restraints is promptly evaluated and authorized by a healthcare provider. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary and may delay appropriate care. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is important but not the immediate priority when dealing with obtaining a prescription for restraints. Documenting the client's condition every 15 minutes (Choice D) is essential for monitoring, but the priority is to secure a prescription for restraints promptly.
4. A nurse is caring for a client who has a prescription for clozapine. Which of the following laboratory values should the nurse monitor?
- A. Monitor blood glucose levels
- B. Monitor WBC count
- C. Monitor platelet count
- D. Monitor hemoglobin levels
Correct answer: B
Rationale: The correct answer is to monitor the WBC count. Clozapine can cause agranulocytosis, a severe decrease in WBC count, which can increase the risk of infection. Monitoring the WBC count is essential to detect this potentially life-threatening condition early. Monitoring blood glucose levels (Choice A) is not directly related to clozapine use. Platelet count (Choice C) and hemoglobin levels (Choice D) are not typically affected by clozapine and are not the priority for monitoring in this case.
5. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?
- A. Offer fluids every 2 hours.
- B. Document the client's behavior prior to being placed in seclusion.
- C. Discuss with the client their inappropriate behavior prior to seclusion.
- D. Assess the client's behavior every hour.
Correct answer: B
Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.
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