ATI Exit Exam

ATI Exit Exam Related

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A nurse is reviewing the medical records of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

  • A. Encourage the client to floss daily.
  • B. Remove fresh flowers from the client's room.
  • C. Provide the client with a stool softener.
  • D. Avoid serving raw vegetables.
Correct Answer: C

Rationale: The correct answer is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, leading to decreased blood clotting ability. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can lead to bleeding in thrombocytopenic clients. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is important for immunocompromised clients to prevent exposure to pathogens but is not specifically related to thrombocytopenia. Avoiding serving raw vegetables (Choice D) is a precaution to reduce the risk of infection in immunocompromised clients but does not directly address the complications of thrombocytopenia.

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A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?

  • A. Do you understand that the voices are not real?
  • B. Why do you think the voices are talking to you?
  • C. Have you tried going to a private place when this occurs?
  • D. What helps you ignore what you are hearing?
Correct Answer: D

Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.

A client has a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?

  • A. Take this medication at bedtime to prevent dizziness.
  • B. Increase your intake of potassium-rich foods.
  • C. Take this medication with food to prevent gastrointestinal upset.
  • D. This medication can increase your blood pressure.
Correct Answer: B

Rationale: The correct instruction that the nurse should include for a client prescribed hydrochlorothiazide is to increase their intake of potassium-rich foods. Hydrochlorothiazide is a diuretic that can lead to potassium depletion, so increasing potassium-rich foods helps prevent hypokalemia. Option A is incorrect because hydrochlorothiazide is usually taken in the morning to prevent diuresis at night. Option C is not necessary as hydrochlorothiazide can be taken with or without food. Option D is incorrect because hydrochlorothiazide is used to lower blood pressure, not increase it.

A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

  • A. Heat the feeding to 105°F (40.6°C).
  • B. Elevate the head of the bed to 45 degrees.
  • C. Flush the tube with 0.9% sodium chloride.
  • D. Verify the pH of the gastric aspirate.
Correct Answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

A nurse is caring for a client who is scheduled for a colonoscopy. Which of the following findings should the nurse report to the provider?

  • A. Client reports taking ibuprofen daily
  • B. Client has a history of asthma
  • C. Client reports drinking one glass of wine daily
  • D. Client has a history of diverticulitis
Correct Answer: A

Rationale: The correct answer is A. Ibuprofen is an NSAID that can increase the risk of bleeding during a colonoscopy due to its effects on platelet function. It is important to report this finding to the provider to consider alternative pain management options. Choices B, C, and D are not the most pertinent to report for a colonoscopy. Asthma and a history of diverticulitis are relevant medical history but do not directly impact the colonoscopy procedure. Drinking one glass of wine daily is not a concern specifically related to the colonoscopy procedure.

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

  • A. Use a 21-gauge needle for injection.
  • B. Inject the medication into the client's deltoid muscle.
  • C. Administer the medication within 5 cm (2 in) of the umbilicus.
  • D. Massage the injection site after administration.
Correct Answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.

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