ATI RN
ATI RN Fundamentals 2023 I Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to prevent irritation and damage to the stoma. If the pouch is too tight, it can cause pressure on the stoma leading to necrosis. If the pouch is too loose, leakage can occur. Applying the pouch while the skin barrier is still damp (choice
A) can lead to poor adhesion. Changing the pouch once every 24 hr (choice
B) may be too frequent and can irritate the skin. Rubbing the peristomal skin dry after cleaning (choice
C) can cause skin irritation.
Question 2 of 5
A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should identify that which of following members of the interdisciplinary team?
Correct Answer: D
Rationale: The correct answer is D: Speech-language pathologist. The speech-language pathologist specializes in evaluating and treating swallowing difficulties (dysphagia) following a stroke. They can help the client with exercises and strategies to improve swallowing function and prevent complications like aspiration pneumonia. The other options are incorrect because:
A) An occupational therapist focuses on helping with activities of daily living;
B) A physical therapist assists with mobility and strength training;
C) A social worker provides emotional support and resources.
Question 3 of 5
A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
Correct Answer: D
Rationale: The correct answer is D: Endotracheal suctioning. This procedure should be prioritized as it is essential for maintaining the client's airway patency and preventing respiratory complications. Endotracheal suctioning helps remove secretions that may obstruct the airway and impede oxygenation. Failure to perform this procedure promptly can lead to respiratory distress or compromise the client's breathing. Urinary catheter care (
A), wound irrigation (
B), and enteral feeding (
C) are important aspects of care but do not take precedence over airway management. Prioritizing endotracheal suctioning ensures the client's respiratory needs are addressed first before attending to other care tasks.
Question 4 of 5
A nurse is caring for a client who has a terminal illness. The client states, 'I am not giving up. I want as much treatment as possible.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: I will contact your provider to discuss your options. This response is appropriate because it demonstrates respect for the client's wishes while also ensuring that the client receives the necessary information to make informed decisions about their care. By contacting the provider, the nurse can facilitate a discussion about the available treatment options, potential benefits, risks, and expected outcomes. This empowers the client to make choices that align with their values and goals.
A: Enjoy the time you have and do the things you want to do - This response may come off as dismissive of the client's desire for treatment and does not address the need for a discussion with the healthcare provider.
B: Hospice care is the best thing for you at this time - While hospice care may be appropriate for some clients with terminal illnesses, it should not be assumed without a thorough discussion with the client and their healthcare provider.
C: You need to understand that you have very little time left - This response is blunt and
Question 5 of 5
A nurse is preparing to administer intermittent tube feeding to a client who has a percutaneous gastrostomy tube. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Flush the client’s tube with 5 mL of water. This is essential to maintain tube patency and prevent clogging. Flushing with water helps clear any residual formula and debris from the tube, ensuring proper delivery of the feeding. Checking pH levels (choice
A) is not necessary for intermittent tube feeding. Checking tube patency every 8 hours (choice
B) is too frequent and may increase the risk of tube dislodgement. Placing the client in a supine position (choice
C) is not necessary for tube feeding.
Therefore, choice D is the most appropriate action to ensure the safe and effective administration of tube feeding.