ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
Correct Answer: A, D, E
Rationale:
Correct
Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect
Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
Question 2 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
Correct Answer: A, B, C
Rationale: The correct actions are A, B, and C.
A) Applying the oxygen source loosely if the SPO2 decreases during the procedure ensures adequate oxygenation.
B) Using surgical asepsis to remove and clean the inner cannula prevents infection.
C) Cleaning the outer surfaces in a circular motion from the stoma site outward helps prevent contamination. Other options are incorrect because:
D) Replacing the tracheostomy ties with new ties is not necessary each time. E) Cutting a slit in gauze squares is not a standard practice for tracheostomy care.
Question 3 of 5
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E.
C: Checking the position of the cannula often ensures proper oxygen delivery and prevents skin breakdown.
D: Reporting nasal stuffiness, nausea, or fatigue is crucial as they may indicate oxygen therapy-related complications.
E: Posting 'no smoking' signs is essential as oxygen is flammable and smoking near oxygen can lead to fires.
A: Applying petroleum jelly can interfere with oxygen delivery and increase the risk of skin breakdown.
B: Removing the nasal cannula during mealtimes can decrease oxygen levels, especially in clients requiring continuous therapy.
Question 4 of 5
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the client asks why water is necessary after the formula drains, the nurse should respond:
Correct Answer: A
Rationale: The correct answer is A: Water helps clear the tube so it doesn't get clogged. Water is necessary after enteral feeding to flush the feeding tube and prevent clogging, ensuring proper delivery of nutrition. Flushing with water also prevents residue buildup and maintains tube patency. This action helps prevent complications such as tube occlusion, which can lead to inadequate delivery of feedings or discomfort for the client. Options B, C, and D are incorrect because the primary reason for flushing the tube with water is to prevent clogging and maintain tube patency, not to secure the tube, provide fluids, or adjust formula concentration.
Question 5 of 5
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (
A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (
C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (
D) is essential but not the priority for this specific procedure.