ATI RN
ATI Exit Exam RN
1. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Elevate the client's legs while in bed.
- B. Reposition the client every 2 hours.
- C. Maintain bed rest for the first 24 hours postoperatively.
- D. Ambulate the client on the first postoperative day.
Correct answer: D
Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.
2. A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?
- A. Eat salty foods to stimulate salivation.
- B. Avoid spicy foods.
- C. Increase intake of high-fiber foods.
- D. Consume cold foods to soothe the mucosa.
Correct answer: D
Rationale: Correct choice: Consume cold foods to soothe the mucosa. Cold foods can help soothe the mucosa and reduce discomfort for patients with stomatitis caused by chemotherapy.\nIncorrect choices: A) Salty foods may irritate the mucosa further. B) Spicy foods can increase discomfort and irritation. C) High-fiber foods may be rough and abrasive, exacerbating the condition.
3. How should a healthcare professional manage a patient with respiratory distress?
- A. Administer bronchodilators
- B. Administer oxygen
- C. Check oxygen saturation
- D. Reposition the patient
Correct answer: B
Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.
4. A nurse is caring for a client who has a new diagnosis of hypercholesterolemia. Which of the following dietary recommendations should the nurse make?
- A. Increase intake of red meat
- B. Consume foods high in saturated fats
- C. Choose foods low in trans fats
- D. Limit intake of vegetables and fruits
Correct answer: C
Rationale: The correct answer is C: 'Choose foods low in trans fats.' Trans fats are known to increase cholesterol levels, so avoiding foods high in trans fats is essential in managing hypercholesterolemia. Option A, increasing intake of red meat, and option B, consuming foods high in saturated fats, can worsen cholesterol levels as they are sources of unhealthy fats. Option D, limiting intake of vegetables and fruits, is incorrect as they are part of a heart-healthy diet and should be encouraged for individuals with hypercholesterolemia.
5. A client has a chest tube. Which of the following interventions should the nurse include?
- A. Clamp the chest tube for 15 minutes every 2 hours.
- B. Maintain the drainage system below the client's chest.
- C. Strip the chest tube every 2 hours.
- D. Keep the collection device at the level of the client's chest.
Correct answer: B
Rationale: Maintaining the chest tube drainage system below the client's chest level is crucial to ensure proper drainage and prevent complications. Clamping the chest tube can lead to a tension pneumothorax, stripping the chest tube is an outdated practice that can cause damage to the tissues, and keeping the collection device at the level of the client's chest can impede proper drainage and lead to fluid accumulation.
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