ATI RN
ATI RN Exit Exam Test Bank
1. A nurse is caring for a client with Alzheimer's disease who wanders frequently. Which of the following interventions should the nurse include in the plan of care?
- A. Place the client in a well-lit area to reduce wandering.
- B. Ensure that the client wears an identification bracelet at all times.
- C. Keep the client's bed in the lowest position.
- D. Use physical restraints to prevent wandering.
Correct answer: B
Rationale: The correct answer is to ensure that the client wears an identification bracelet at all times. This intervention helps staff recognize clients who wander and ensures their safety. Placing the client in a well-lit area (Choice A) may be helpful in some cases but does not directly address the issue of wandering. Keeping the client's bed in the lowest position (Choice C) is important for fall prevention but is not directly related to wandering behavior. Using physical restraints (Choice D) is not recommended as the first-line intervention for wandering and should be avoided due to ethical concerns and potential risks.
2. A nurse is caring for a client who has depression and reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?
- A. Serotonin syndrome
- B. Tardive dyskinesia
- C. Pseudo-parkinsonism
- D. Acute dystonia
Correct answer: A
Rationale: The correct answer is A: Serotonin syndrome. When a client takes St. John's wort, a herbal supplement, along with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of developing serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition characterized by symptoms such as confusion, agitation, fever, sweating, shivering, tremors, muscle rigidity, and in severe cases, seizures and coma. It is crucial for the nurse to monitor the client for these symptoms. Choices B, C, and D are incorrect because tardive dyskinesia is associated with long-term use of antipsychotic medications, pseudo-parkinsonism is a side effect of antipsychotic medications like haloperidol, and acute dystonia is a side effect of antipsychotic medications characterized by sustained muscle contractions.
3. Which of the following is a type of heart attack that occurs when the blood supply to part of the heart muscle is severely reduced or stopped?
- A. Myocardial infarction
- B. Angina
- C. Stroke
- D. Congestive heart failure
Correct answer: A
Rationale: The correct answer is A: Myocardial infarction. Myocardial infarction, commonly known as a heart attack, occurs when the blood supply to part of the heart muscle is severely reduced or stopped, leading to tissue damage or death. Angina (choice B) is chest pain or discomfort that occurs when the heart muscle doesn't get enough oxygen-rich blood. Stroke (choice C) is a condition where the blood supply to the brain is interrupted or reduced. Congestive heart failure (choice D) is a chronic condition where the heart muscle doesn't pump blood as well as it should.
4. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes mellitus. Which of the following client statements indicates a need for further teaching?
- A. I will check my blood glucose level once a week.
- B. I will eat a snack if my blood glucose level is above 200 mg/dL.
- C. I will take my insulin as prescribed, even when I am feeling well.
- D. I will avoid physical activity if my blood glucose level is below 100 mg/dL.
Correct answer: B
Rationale: The correct answer is B. Clients should eat a snack when their blood glucose level is low, typically below 70-100 mg/dL, not when it is high. Eating a snack when the blood glucose level is above 200 mg/dL can exacerbate hyperglycemia. Choice A is correct as checking blood glucose levels regularly is important in managing diabetes. Choice C is also correct as adherence to prescribed insulin therapy is crucial. Choice D is incorrect as physical activity can help lower blood glucose levels, especially when they are above the target range.
5. A nurse is caring for a client who has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?
- A. Replace the bag and tubing every 24 hr
- B. Flush the tubing with 10 mL water every 6 hr
- C. Admin the feeding by gravity drip
- D. Heat the formula prior to infusion
Correct answer: B
Rationale: Flushing the tubing with 10 mL of water every 6 hours helps prevent clogging when using high-viscosity formulas.
Similar Questions
Access More Features
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 90 days access @ $149.99