ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Auscultating bowel sounds is important to ensure proper GI function before administering enteral feedings.
B: Assisting the client to an upright position helps prevent aspiration during feeding.
C: Testing the pH of gastric aspirate ensures the tube is correctly positioned in the stomach and not in the lungs.
Incorrect
Choices:
D: Warming the formula is not a necessary step prior to administering enteral feedings.
E: Discarding residual gastric contents is not typically done before administering enteral feedings unless there is a specific reason to do so.
Question 2 of 5
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
Correct Answer: A, B, D
Rationale:
Correct Answer: A, B, D
Rationale:
A: The physical therapist not ambulating the client is crucial information as it indicates a change in the client's care plan due to the skin barrier issue.
B: The skin barrier's behavior in different positions is relevant to understanding the problem and potential solutions.
D: The wound care nurse's visit is important as it shows ongoing management of the skin barrier issue.
Summary:
C: The client's feelings about physical therapy are not as critical as the actual care provided.
E: The client's food intake is not directly related to the issue with the skin barrier.
F, G: No information is provided about these options in the scenario.
Question 3 of 5
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention?
Correct Answer: C
Rationale: The correct answer is C because the client expressing uncertainty about their identity indicates a potential identity crisis, which is a fundamental developmental task for young adults. This issue can impact various aspects of the client's life, including relationships, career choices, and overall well-being. Addressing this issue first can help the client gain clarity and confidence in navigating other challenges.
Choices A, B, and D are important concerns, but they are more specific and situational compared to the broader existential crisis of self-identity presented in option C. Prioritizing the identity crisis can lay the foundation for addressing other issues effectively.
Question 4 of 5
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him?
Correct Answer: D
Rationale:
Correct Answer: D (Social worker)
Rationale: The social worker is the most appropriate referral for the older adult facing difficulty in preparing nutritious meals. Social workers can assess the client's social needs, such as access to community resources, meal delivery services, or support groups. They can also help with financial assistance or other social services to ensure the client's well-being.
Summary of other choices:
A: Registered dietitian - While a dietitian can provide nutritional guidance, the client's issue is not solely about dietary recommendations but also about access to nutritious meals.
B: Occupational therapist - OTs focus on assisting clients with daily living activities and functional independence, not specifically addressing the client's meal preparation concerns.
C: Physical therapist - PTs focus on rehabilitation and physical function, not directly related to the client's nutritional challenges.
Question 5 of 5
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all.
Correct Answer: B, C
Rationale: The correct answers are B and C. Impaired circulation (
B) can lead to poor wound healing by limiting the delivery of oxygen and nutrients to the wound site. In this case, the adolescent has undergone surgery, which can disrupt circulation. Impaired/suppressed immune system (
C) can also hinder wound healing as the immune response is crucial for fighting off infection and promoting healing. The client's successful ambulation and toleration of a regular diet suggest good overall health, reducing the risk of malnutrition (
D) and poor wound care (E). Extremes in age (
A) are not relevant in this case.