ATI RN
ATI RN Fundamentals 2019 Questions
Question 1 of 5
A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Order the Items
Source Container
Correct Answer: E,C,D,B,A
Rationale: The correct sequence for performing a physical assessment of a client's abdomen is as follows:
E: Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.
C: Percuss all four quadrants of the abdomen to measure sound quality.
D: Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
B: Listen to the abdominal arteries using the bell of a stethoscope.
A: Provide adequate lighting to inspect the abdomen.
Rationale:
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Step E is performed first to locate the liver and spleen borders.
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Step C follows to assess sound quality in all quadrants.
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Step D checks for tenderness, which should be done next.
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Step B involves listening to abdominal arteries for abnormalities.
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Step A provides proper lighting to inspect the abdomen thoroughly.
Other choices are incorrect:
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Choice F and G are not relevant to the
Question 2 of 5
A nurse is preparing to administer several medications via NG tube to a client who is receiving continuous tube feeding. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Flush the NG tube with 5 mL of sterile water prior to administration. This action ensures that the NG tube is clear of any residual formula or medication before administering new medications. Mixing medications together in a single syringe (
A) can lead to interactions or reduced efficacy. Diluting each crushed medication with sterile water (
B) may alter the medication's effectiveness. Combining the medications with the formula in the feeding bag (
D) can also affect medication absorption. Flushing the NG tube with water ensures proper delivery of medications without interference.
Question 3 of 5
A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?
Correct Answer: A
Rationale: The correct answer is A: Performing a simple dressing change. This task is appropriate for delegation to assistive personnel as it is within their scope of practice and does not require specialized skills. Assistive personnel are trained to perform basic care activities under the nurse's supervision.
Choices B and C involve invasive procedures that require specialized training and should not be delegated.
Choice D involves clinical judgment and assessment, which are the responsibility of the nurse.
Therefore, choice A is the most appropriate task to delegate in this scenario.
Question 4 of 5
A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Dilute each crushed medication with sterile water. This is the appropriate action because mixing medications together in a single syringe (choice
A) can lead to drug interactions. Flushing the NG tube with sterile water (choice
C) is important but not directly related to administering medications. Combining the medications with the formula in the feeding bag (choice
D) is incorrect as it may alter the formula's composition. It is crucial to dilute medications individually to ensure proper absorption and prevent clogging of the tube.
Question 5 of 5
A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Address all questions to the interpreter. This is the best action because it ensures effective communication between the nurse and the client who speaks a different language. The interpreter serves as a bridge to convey accurate information and facilitate understanding. Nodding (
A) may not guarantee comprehension. Using medical terminology (
C) can confuse the client. Recommending a same-gender interpreter (
D) is not essential for obtaining informed consent.