a hospice nurse is visiting with the son of a client who has terminal cancer the son reports sleeping very little during the past week due to caring f
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

2. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?

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 nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

Correct answer: C

Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.

4. How should fluid balance be monitored in a patient receiving diuretics?

Correct answer: A

Rationale: Corrected Question: To assess fluid balance in a patient receiving diuretics, monitoring daily weight is the most accurate method. This is because diuretics primarily affect fluid levels in the body, leading to changes in weight due to fluid loss. While monitoring intake and output, checking for edema, and monitoring blood pressure are important aspects of patient care, they do not provide as direct and accurate information about fluid balance as daily weight monitoring specifically in patients on diuretics.

5. A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?

Correct answer: D

Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.

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