ATI RN
ATI Exit Exam 2024
1. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?
- A. Apply the patch to the same location each time.
- B. Rotate the patch site daily to avoid skin irritation.
- C. Apply the patch in the morning and remove it at bedtime.
- D. Keep the patch on at all times, even during a bath.
Correct answer: C
Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.
2. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Blood pressure of 130/85 mm Hg
- C. Coughing up small amounts of sputum
- D. Absent gag reflex
Correct answer: D
Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.
3. 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.
4. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Take a tablet every 5 minutes for pain relief, up to three doses.
- B. Take this medication with a glass of water.
- C. Chew the tablet for faster absorption.
- D. Store the tablets in a refrigerator.
Correct answer: A
Rationale: The correct answer is A: 'Take a tablet every 5 minutes for pain relief, up to three doses.' Nitroglycerin sublingual tablets are used to relieve chest pain or to prevent chest pain before activities known to cause angina. The tablets should be taken every 5 minutes for pain relief, up to three doses, as prescribed. Choice B is incorrect because nitroglycerin sublingual tablets should be placed under the tongue until they dissolve, not taken with water. Choice C is incorrect because nitroglycerin sublingual tablets should not be chewed but placed under the tongue for absorption. Choice D is incorrect because nitroglycerin tablets should be stored in their original container at room temperature away from light and moisture.
5. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct answer: C
Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.
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