ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?
- A. Elevate the head of the bed 45 degrees during feedings.
- B. Place the client in the left lateral position for 30 minutes after feedings.
- C. Flush the tube with 30 mL of sterile water before each feeding.
- D. Check gastric residuals every 8 hours.
Correct answer: A
Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.
2. A client is starting a new prescription for enalapril. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Rise slowly from a sitting position.
- C. Avoid salt substitutes.
- D. Avoid exposure to sunlight.
Correct answer: C
Rationale: The correct instruction for a client starting enalapril is to avoid salt substitutes. Salt substitutes may contain potassium, which could lead to elevated potassium levels when combined with enalapril, increasing the risk of hyperkalemia. Choices A, B, and D are incorrect because there is no specific need to take enalapril with food, rise slowly from a sitting position, or avoid exposure to sunlight when taking this medication.
3. Is the parietal pericardium attached to the surface of the heart?
- A. True
- B. False
- C. Not Sure
- D. None of the above
Correct answer: True
Rationale: The parietal pericardium is a tough, fibrous outer layer that is attached to the diaphragm and the sternum but not directly to the surface of the heart. It forms a sac around the heart known as the pericardial sac. Therefore, the statement that the parietal pericardium is attached to the surface of the heart is false.
4. A client with pre-dialysis end-stage kidney disease is being taught about diet. Which of the following instructions should the nurse include?
- A. Increase intake of dietary phosphorus.
- B. Eliminate foods high in protein from your diet.
- C. Reduce intake of foods high in potassium.
- D. Increase intake of sodium-containing foods.
Correct answer: C: "Reduce intake of foods high in potassium."
Rationale: In pre-dialysis end-stage kidney disease, reducing intake of foods high in potassium is crucial as impaired kidney function can lead to potassium buildup in the blood, which can be dangerous. High potassium levels can cause irregular heartbeats and even cardiac arrest. Therefore, advising the client to reduce potassium-rich foods is essential to prevent complications. Choices A, B, and D are incorrect. Increasing dietary phosphorus, eliminating foods high in protein, or increasing sodium-containing foods are not appropriate recommendations for a client with pre-dialysis end-stage kidney disease as they can exacerbate the condition.
5. Which condition is characterized by an inability to effectively pump blood, leading to fluid buildup and swelling in the body?
- A. Heart failure
- B. Cardiomyopathy
- C. Angina
- D. Myocarditis
Correct answer: A
Rationale: Heart failure is the correct answer. It is a condition where the heart is unable to pump blood effectively, resulting in fluid accumulation and swelling in the body. Cardiomyopathy is a disease of the heart muscle that affects its ability to pump blood but is not the specific condition described in the question. Angina is chest pain or discomfort caused by reduced blood flow to the heart, not directly related to fluid buildup and swelling. Myocarditis is inflammation of the heart muscle and does not necessarily involve the inability to pump blood effectively.
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