ATI RN
ATI Fundamentals Proctored Exam 2023
1. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?
- A. Confront the client about this behavior.
- B. Express sympathy for the client's situation.
- C. Speak assertively to the client.
- D. Stand within 30 cm (1 ft) of the client when speaking with them.
Correct answer: Confront the client about this behavior.
Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.
2. Which should the nurse teach to parents regarding oral health of children? (Select all that apply.)
- A. Fluoridated water should be used.
- B. Early childhood caries is a preventable disease
- C. All options are correct
- D. Dental hygiene should begin with the first tooth eruption
Correct answer: C
Rationale: Fluoridated water helps prevent caries, early childhood caries is preventable, and dental hygiene should start with the first tooth eruption.
3. A client is starting therapy with Metformin. Which of the following instructions should the nurse include?
- A. Take this medication with your first bite of food.
- B. Take this medication on an empty stomach.
- C. Take this medication before bedtime.
- D. Take this medication every other day.
Correct answer: A
Rationale: Metformin should be taken with meals to reduce gastrointestinal side effects and ensure better absorption. Instructing the client to take the medication with the first bite of food helps in achieving optimal effectiveness and minimizes the risk of side effects like nausea or upset stomach. Choice B is incorrect because taking Metformin on an empty stomach can lead to increased gastrointestinal side effects. Choice C is incorrect as there is no specific timing requirement for taking Metformin before bedtime. Choice D is incorrect as Metformin is usually taken daily, not every other day.
4. A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?
- A. Keep calcium gluconate at the bedside.
- B. Monitor blood pressure every 2 hours.
- C. Limit IV exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct answer: C
Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.
5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 48 hours.
- B. Change the TPN tubing every 24 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Monitor the client's weight every 72 hours.
Correct answer: B
Rationale: The correct answer is to change the TPN tubing every 24 hours. This action helps reduce the risk of infection because the high glucose content of TPN promotes bacterial growth. Choice A is incorrect as changing the tubing every 48 hours would not provide adequate infection prevention. Option C, monitoring urine output, is important for assessing renal function but is not directly related to preventing TPN-related infections. Option D, monitoring weight, is essential for assessing nutritional status but does not directly address infection prevention in TPN administration.
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