ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse administers 200 mL of enteral nutrition via a client's gastrostomy (GT) tube. The nurse flushes the feed bolus with 30 mL of water before and after the feed. How many mL does the nurse document as intake in the I&O?
Correct Answer: 260
Rationale: The correct answer is 260 mL.
To calculate the total intake documented in the I&O, we add the enteral nutrition (200 mL) to the water used for flushing before (30 mL) and after (30 mL) the feed. 200 mL (nutrition) + 30 mL (before flush) + 30 mL (after flush) = 260 mL. This total reflects the actual volume that entered the client's system.
Choices A-G are incorrect as they do not consider the additional water used for flushing before and after the feed, resulting in an inaccurate documentation of intake.
Question 2 of 5
A nurse is providing education about when health care referrals would be appropriate. When should a healthcare provider order a referral?
Correct Answer: B
Rationale: The correct answer is B: When the care needed for the client is out of their scope of practice. This is the correct choice because healthcare providers should refer clients when they require specialized care beyond the nurse's knowledge or skills. Referrals ensure that clients receive appropriate and safe care. The other options are incorrect: A is irrelevant to the client's needs, C is not a valid reason for a referral as all clients deserve care, and D is a non-clinical reason.
Question 3 of 5
A nurse is caring for a client diagnosed with end-stage liver cancer. Which response is an indication the client is in the denial phase of the grief process?
Correct Answer: A
Rationale: The correct answer is A because the client is exhibiting denial by dismissing the doctor's prognosis as an exaggeration to avoid facing the reality of their limited time left. This response indicates a refusal to accept the severity of their condition, a common coping mechanism in the denial phase of grief.
Choice B reflects anger towards the doctor, not denial.
Choice C suggests physical symptoms rather than denial.
Choice D shows acceptance and gratitude, not denial.
Question 4 of 5
A client asks the nurse about a prescription for the antihistamine, diphenhydramine (Benadryl). The nurse should teach the client that this medication is contraindicated in clients who have a history of which condition?
Correct Answer: C
Rationale: The correct answer is C: Glaucoma. Diphenhydramine is contraindicated in clients with glaucoma because it can increase intraocular pressure, potentially exacerbating the condition. This can lead to vision problems and worsen the symptoms of glaucoma. Asthma (choice
A), hypertension (choice
B), and depression (choice
D) are not contraindications for diphenhydramine use. Asthma and hypertension may actually benefit from the antihistamine effects of diphenhydramine. Depression is not directly affected by diphenhydramine use.
Question 5 of 5
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an abdominal wound. The nurse should understand that the JP drain was placed for which purpose?
Correct Answer: D
Rationale: The correct answer is D:
To prevent fluid from accumulating in the wound. A Jackson-Pratt drain is a closed suction system used to remove excess fluid from a surgical site to prevent seroma or hematoma formation. By creating negative pressure, the drain helps to promote wound healing and reduce the risk of infection.
Choice A is incorrect because a JP drain is not used for medication administration.
Choice B is incorrect as wound dressings are still needed despite the drain.
Choice C is incorrect as the primary purpose of a JP drain is not to limit bleeding but to remove fluid.