ATI RN
ATI Exit Exam
1. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?
- A. The client's pulse oximetry level is 96%.
- B. The client develops hiccups.
- C. The ECG shows pacing spikes after the QRS complex.
- D. The client's heart rate is 90 beats per minute.
Correct answer: C
Rationale: The correct answer is C. Pacing spikes after the QRS complex indicate a malfunction of the pacemaker and should be reported. Choice A is not directly related to the pacemaker function. Choice B, hiccups, are common and not typically associated with pacemaker issues. Choice D, a heart rate of 90 beats per minute, is within the normal range and does not indicate a pacemaker malfunction.
2. How is the stomach protected from damage by gastric acid?
- A. enzymes present in the stomach
- B. a protective bacteria in the stomach
- C. bicarbonate present in the stomach
- D. the mucus lining of the stomach
Correct answer: D
Rationale: The correct answer is D. The stomach is protected from gastric acid by a thick mucus lining that acts as a physical barrier, preventing the acid from eroding the stomach walls. Enzymes in the stomach help with digestion but do not play a significant role in protecting the stomach from acid damage, so choice A is incorrect. While some bacteria in the stomach can be beneficial, they do not primarily protect the stomach from gastric acid, making choice B incorrect. Bicarbonate, a base, can neutralize acid, but it is not the primary defense mechanism against gastric acid in the stomach, so choice C is also incorrect.
3. While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
- A. Obtain a cardiology consult.
- B. Suction the client less frequently.
- C. Administer an antidysrhythmic medication.
- D. Perform pre-oxygenation prior to suctioning.
Correct answer: D: Perform pre-oxygenation prior to suctioning.
Rationale: When a client's heart rate increases and becomes irregular during suctioning of an endotracheal tube, it indicates potential hypoxemia. Performing pre-oxygenation before suctioning helps prevent hypoxemia and subsequent dysrhythmias. This intervention ensures that the client has adequate oxygen reserves before the procedure, reducing the risk of complications related to suctioning.
4. After reviewing the health and dental histories, the dental hygienist has adequate information to begin dietary counseling with the patient. Providing a standardized, low-carbohydrate menu is sufficient for most patients with a high caries rate.
- A. Both statements are true
- B. Both statements are false
- C. The first statement is true; the second is false
- D. The first statement is false; the second is true
Correct answer: B
Rationale: Both statements are false. Dietary counseling should be personalized, and a standardized low-carbohydrate menu is not sufficient for all patients.
5. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?
- A. Allow the client to continue the ritualistic behavior initially
- B. Immediately stop the client from performing the ritual
- C. Encourage the client to perform the ritual more quickly
- D. Provide a distraction to interrupt the ritual
Correct answer: A
Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.
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