ATI Exit Exam 2024

Correct Answer: D

Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.

Correct Answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism adhere to specific dietary restrictions, which include consuming unleavened bread. Providing unleavened bread aligns with the client's religious beliefs and dietary requirements. Choices A, B, and D are incorrect. Serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not directly related to the dietary restrictions observed during the Passover holiday in Orthodox Judaism.

Correct Answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This is important because discussing a client's information violates confidentiality policies. Contacting the client's family (Choice A) is not appropriate as it may breach confidentiality further. Notifying the client's provider (Choice B) is not the initial action to take in this situation, as addressing it within the facility should come first. Filing a complaint with the facility's ethics committee (Choice C) is not the immediate step and might not directly address the issue at hand.

Correct Answer: C

Rationale: Using an abduction pillow between the client's legs is essential in maintaining proper alignment and preventing dislocation of the hip joint following a hip arthroplasty. Encouraging the client to lie flat in bed (Choice A) is not recommended as early mobilization is crucial for preventing complications. Applying heat to the incision site (Choice B) is not typically done immediately postoperatively. Placing a trochanter roll under the client's knees (Choice D) is not as beneficial as using an abduction pillow to maintain proper positioning.

Correct Answer: D

Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.