ATI Comprehensive Exit Exam 2023

Correct Answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

Correct Answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to monitor for black, tarry stools while taking clopidogrel. This is important because it helps detect gastrointestinal bleeding, a potential side effect of the medication. Choice A is incorrect as there is no specific requirement to avoid foods high in fat while taking clopidogrel. Choice C is incorrect as grapefruit juice interaction is not a concern with clopidogrel. Choice D is incorrect as clopidogrel can be taken with or without food.

Correct Answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

Correct Answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

Correct Answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.