ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Question 1 of 5
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
Correct Answer: C
Rationale: The correct answer is C: Empty the reservoir. This is the appropriate action because an expanded and half-full Jackson-Pratt drain reservoir indicates an accumulation of fluids, which may lead to complications if not addressed promptly. By emptying the reservoir, you can prevent potential issues such as infection or blockage. Leaving it until the end of the shift (
A) is not advisable as it can lead to worsening of the condition. Removing the drain (
B) without proper assessment or instructions can be harmful to the client. Notifying the surgeon about the blood loss (
D) is important but should be done after taking immediate action to address the issue by emptying the reservoir.
Extract:
A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus.
Question 2 of 5
Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Assess the client for adverse reactions. This action should be taken first as it is crucial to ensure the client's safety and well-being. By assessing for adverse reactions, the nurse can promptly identify any immediate threats to the client's health and intervene accordingly. Vital signs (
A) can wait until the client's immediate safety is ensured. Notifying the healthcare provider (
B) and documenting the incident (
C) can be done after the client's assessment. Assessing for adverse reactions takes priority over other actions as it directly addresses the client's immediate needs.
Extract:
A nurse is documenting client care.
Question 3 of 5
Which of the following abbreviations should the nurse use?
Correct Answer: C
Rationale: The correct answer is C: BRP' for bathroom privileges. The nurse should use this abbreviation because it is a commonly accepted and recognized abbreviation in healthcare settings. It is important for healthcare professionals to use standardized abbreviations to ensure clear and accurate communication.
Choice A, SC', is incorrect because the standard abbreviation for subcutaneous is "SQ" or "subQ."
Choice B, SS', is incorrect as the standard abbreviation for a sliding scale is "SS."
Choice D, OJ', is incorrect as the standard abbreviation for orange juice is "OJ." It is crucial for nurses to use correct and universally understood abbreviations to prevent misunderstandings and ensure patient safety.
Extract:
A nurse is caring for a client. Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6°C (99.7°F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5°C (99.5°F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air
Question 4 of 5
Select the 4 findings that require immediate follow-up.
Correct Answer: B,D,E
Rationale: The correct answer is B, D, E. These findings require immediate follow-up because they are vital signs that provide crucial information about the patient's cardiovascular and respiratory status. Blood pressure (
B) can indicate circulation and perfusion issues. Pulse oximetry (
D) measures oxygen saturation, vital for assessing respiratory function. Heart rate (E) reflects cardiac function and can indicate cardiovascular or systemic issues. Temperature (
A) and respiratory rate (
C) are important but may not always require immediate follow-up. Level of consciousness (F) and skin color/temperature (G) are important but do not directly assess cardiovascular or respiratory function.
Extract:
Question 5 of 5
A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Place the extremity in a dependent position. Placing the extremity in a dependent position helps to promote venous distention, making it easier to locate and access the vein for IV insertion. This position allows gravity to assist in filling the veins with blood, making them more visible and accessible.
Choice A is incorrect because the most distal site should be chosen to preserve more proximal sites for future access.
Choice B is incorrect as applying a cool compress can cause vasoconstriction, making it more difficult to visualize and access the vein.
Choice C is incorrect as the tourniquet should be placed above the proposed insertion site to aid in venous engorgement.