ATI RN
ATI Comprehensive Exit Exam 2023 With NGN Quizlet
1. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?
- A. Remove the client's restraint every 4 hours.
- B. Document the client's condition every 15 minutes.
- C. Attach the restraint to the bed's side rails.
- D. Request a PRN restraint prescription for clients who are aggressive.
Correct answer: B
Rationale: The correct answer is B. When updating protocols for the use of belt restraints, it is essential to document the client's condition every 15 minutes. This frequent documentation helps ensure the client's safety and allows for timely assessment of the need for continued restraint use. Choice A is incorrect because restraints should be removed and reassessed more frequently than every 4 hours. Choice C is incorrect as restraints should not be attached to the bed's side rails due to entrapment risks. Choice D is also incorrect as restraints should not be used as needed (PRN) but rather based on a specific prescription and assessment indicating the need for restraint use.
2. A client has been prescribed sertraline for depression, and the nurse is providing discharge instructions. Which dietary instruction should the nurse include?
- A. Avoid foods high in sodium.
- B. Avoid foods high in calcium.
- C. Avoid foods high in tyramine.
- D. Avoid foods high in potassium.
Correct answer: C
Rationale: Clients prescribed sertraline should avoid foods high in tyramine to prevent a hypertensive crisis. Sertraline, an antidepressant belonging to the selective serotonin reuptake inhibitor (SSRI) class, can interact with tyramine-rich foods, potentially causing a dangerous increase in blood pressure known as a hypertensive crisis. Choices A, B, and D are incorrect because there is no specific dietary restriction related to sodium, calcium, or potassium intake when taking sertraline.
3. The nurse is caring for a client with an astrocytoma. The client asks, 'What do astrocytes do in the brain?' What is the nurse's best response?
- A. Astrocytes help to nourish and support neurons in the brain.
- B. Astrocytes are a type of neuron that transmit electrical signals.
- C. Astrocytes are involved in immune responses in the brain.
- D. Astrocytes help regulate blood flow in the brain.
Correct answer: A
Rationale: Astrocytes play a crucial role in supporting and nourishing neurons by providing metabolic support, maintaining the blood-brain barrier, and regulating the chemical environment of the brain. While astrocytes are essential for brain function, they are not neurons and do not transmit electrical signals (Choice B). Astrocytes are not primarily involved in immune responses in the brain (Choice C) or in regulating blood flow in the brain (Choice D), although they indirectly influence blood flow through their support functions.
4. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
- A. Cleanse the bag every 24 hours
- B. Cleanse the bag every 48 hours
- C. Use tap water
- D. Flush the tube every 4 hours
Correct answer: A
Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.
5. After a thoracentesis on a client with a pleural effusion, which nursing intervention is most important post-procedure?
- A. Monitor for signs of infection.
- B. Assess for signs of bleeding or hematoma.
- C. Monitor vital signs and respiratory status.
- D. Instruct the client to rest and limit physical activity.
Correct answer: B
Rationale: The correct answer is to assess for signs of bleeding or hematoma. After a thoracentesis, it is crucial to monitor for any bleeding or hematoma formation at the puncture site, as this can lead to complications. Monitoring for signs of infection (Choice A) is essential but is usually a delayed concern compared to the immediate risk of bleeding post-procedure. While monitoring vital signs and respiratory status (Choice C) is important, assessing for bleeding takes precedence to address any immediate complications. Instructing the client to rest and limit physical activity (Choice D) is relevant for general post-procedure care but is not the most critical intervention in this scenario.
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