ATI RN
ATI Exit Exam 2024
1. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the healthcare professional take first?
- A. Check the residual volume before administering the feeding
- B. Elevate the head of the bed to 30 degrees
- C. Flush the tube with 10 mL of sterile water
- D. Verify the client's tube placement
Correct answer: D
Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.
2. A nurse is preparing to administer vancomycin IV to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
- A. Administer the medication over 60 minutes
- B. Monitor the client's blood glucose level during administration
- C. Infuse the medication rapidly to reduce the risk of infection
- D. Administer the medication using a filter needle
Correct answer: A
Rationale: The correct action the nurse should take is to administer the medication over 60 minutes. This is important because administering vancomycin over 60 minutes helps prevent red man syndrome, a reaction that can occur with rapid infusion. Monitoring the client's blood glucose level (Choice B) is unrelated to vancomycin administration. Infusing the medication rapidly (Choice C) is incorrect and can lead to adverse reactions. Administering the medication using a filter needle (Choice D) is unnecessary for vancomycin administration.
3. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing any tears
- B. Your baby needs an IV because her fontanels are bulging
- C. Your baby needs an IV because she is breathing slower than normal
- D. Your baby needs an IV because her heart rate is decreasing
Correct answer: A
Rationale: The correct answer is A. A lack of tear production is a sign of severe dehydration in infants, indicating the need for IV therapy. Option B, bulging fontanels, is a sign of increased intracranial pressure, not dehydration. Option C, breathing slower than normal, and Option D, decreasing heart rate, are not specific signs of severe dehydration that would indicate the need for IV therapy in this case.
4. A healthcare provider is reviewing the medical record of a client who has Cushing's disease. Which of the following findings should the healthcare provider expect?
- A. Decreased serum glucose level
- B. Increased lymphocyte count
- C. Increased serum potassium level
- D. Decreased serum sodium level
Correct answer: C
Rationale: In Cushing's disease, there is increased cortisol production, which can lead to various metabolic disturbances. One of the common findings is an increased serum potassium level. The other options are incorrect because Cushing's disease typically causes hyperglycemia, not decreased serum glucose levels (A), lymphocytopenia, not increased lymphocyte count (B), and hyponatremia, not decreased serum sodium level (D).
5. 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.
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