ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Question 1 of 5
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Identify the impact of the mastectomy on the client's body image. The first step is to assess the client's emotional state and address her feelings of sadness and avoidance, which are indications of body image issues. By identifying the impact of the mastectomy on body image, the nurse can provide appropriate emotional support and interventions. Referring the client to a support group (
A) can be helpful but should come after understanding the client's individual needs. Encouraging the client to assist with dressing changes (
C) may not address the underlying emotional distress. Providing a mirror (
D) may worsen the client's distress if she is not ready to confront her incisions.
Question 2 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.
Question 3 of 5
A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale: Applying a bath blanket between the client and a cooling blanket helps to prevent direct contact between the cooling blanket and the client's skin, reducing the risk of hypothermia. This method promotes gradual cooling and prevents sudden temperature changes, which can be harmful. It also helps to regulate the client's body temperature effectively.
Summary of Incorrect
Choices:
B: Placing ice packs on the client's neck and behind the knees can lead to localized cooling and may not effectively reduce the overall body temperature in a client with a high fever.
C: Giving the client a sponge bath using an alcohol-water solution can lead to evaporative cooling, which may cause the client's body temperature to decrease too rapidly, potentially leading to complications.
D: Covering the client with heavy blankets after shivering subsides can trap heat and hinder the cooling process, making it difficult to lower the client's fever effectively.
Question 4 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: A
Rationale: The correct answer is A: Gastric residual of 300 mL at the end of the shift. This is unexpected because a large gastric residual volume can indicate feeding intolerance, delayed gastric emptying, or an increased risk of aspiration. It may require adjustments in the feeding rate or formulation.
B: Weight gain is expected due to continuous enteral feeding.
C: Blood glucose level within normal range is expected.
D: Diarrhea can be a side effect of enteral feeding but occurring one time in a 24-hr period is not unexpected.
In summary, the unexpected finding of a large gastric residual volume indicates potential issues with the enteral feeding process, while the other choices are within expected parameters.
Question 5 of 5
A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: "I should gradually increase the time that I wear the hearing aid." This statement indicates an understanding of the teaching because it reflects the importance of gradually acclimating to wearing the hearing aid to prevent discomfort and allow the client to adjust to the device. By gradually increasing the wearing time, the client can adapt to the sounds and sensations of the hearing aid.
Choice A is incorrect because turning the hearing aid up to maximum volume can be damaging to the ears and may not be necessary for all situations.
Choice B is incorrect because hearing aids typically do not need to be replaced annually unless there are specific issues.
Choice C is incorrect as leaving the battery in the hearing aid when not in use can lead to battery drainage and potential damage.