ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?
- A. Check for the presence of bowel sounds every 8 hours.
- B. Flush the NG tube every 24 hours.
- C. Provide the client with sips of water every 2 hours.
- D. Keep the client's head of the bed elevated to 45 degrees.
Correct answer: D
Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.
2. What are the signs of compartment syndrome?
- A. Unrelieved pain, pallor, pulselessness
- B. Muscle weakness, hyporeflexia
- C. Pins-and-needles sensation, swelling
- D. Severe swelling and tightness in the affected extremity
Correct answer: A
Rationale: The correct signs of compartment syndrome include unrelieved pain, pallor, and pulselessness due to increased pressure within a muscle compartment. Choice B, muscle weakness, and hyporeflexia are not typical signs of compartment syndrome. Choice C, pins-and-needles sensation and swelling, are not specific signs of compartment syndrome. Choice D, severe swelling and tightness in the affected extremity, could be seen in compartment syndrome but are not the primary signs.
3. The lobe of the brain that contains the auditory receptive areas is the ____________ lobe.
- A. temporal
- B. frontal
- C. parietal
- D. occipital
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?
- A. He has fresh, active upper GI bleeding.
- B. He needs immediate saline gastric lavage.
- C. His gastric bleeding occurred 2 hours earlier.
- D. He needs a transfusion of packed RBCs.
Correct answer: C
Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.
5. A client has a new prescription for Oxycodone/Acetaminophen, and the nurse is providing discharge instructions. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Avoid taking additional Acetaminophen while on this medication.
- C. Increase your intake of fiber while on this medication.
- D. Avoid taking the medication before bedtime.
Correct answer: B
Rationale: The correct instruction for a client with a prescription for Oxycodone/Acetaminophen is to avoid taking additional Acetaminophen while on this medication. Combining medications containing Acetaminophen can lead to exceeding the maximum recommended dose and increase the risk of liver toxicity. Therefore, it is crucial for the nurse to emphasize the importance of not taking extra Acetaminophen while on this prescription to ensure the client's safety and well-being. Choices A, C, and D are incorrect. Taking Oxycodone/Acetaminophen on an empty stomach is not necessary; increasing fiber intake is not directly related to this medication, and avoiding taking the medication before bedtime is not a specific concern associated with this prescription.
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