ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
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. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Obtain the client's vital signs. This is the first action the nurse should take because administering a larger IV fluid bolus than prescribed can potentially lead to adverse effects such as fluid overload or electrolyte imbalances. By obtaining the client's vital signs, the nurse can assess for any immediate signs of complications, such as changes in blood pressure, heart rate, or respiratory rate. This immediate assessment is crucial in ensuring the client's safety and well-being.
Other choices are incorrect:
A: Documenting the fluid infusion is important, but not the first priority in this situation.
B: Completing an incident report should be done after addressing the immediate needs of the client.
D: Reporting the incident to the unit manager is important, but not before ensuring the client's immediate safety.
Question 2 of 5
A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Flush the tubing with 10 mL of water every 2 hr. Flushing the tubing helps prevent clogging and ensures proper delivery of the enteral feed. It also helps maintain tube patency and reduces the risk of infection. Aspiration of residual volume (choice
B) is not recommended as it can lead to inaccurate readings and potential complications. Heating the formula (choice
A) to a specific temperature is not necessary and can cause burns. Changing the tubing set (choice
D) every 72 hours is not evidence-based practice and can increase the risk of contamination.
Question 3 of 5
A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Dilute each crushed medication with sterile water. This is the correct action because medications administered via NG tube should be in liquid form to prevent clogging and ensure proper absorption. Diluting each crushed medication with sterile water helps maintain the medication's consistency and facilitates its passage through the tube. Mixing medications together in a single syringe (choice
A) may cause interactions or alter the effectiveness of the medications. Flushing the NG tube with sterile water (choice
C) is important but not directly related to administering medications. Combining medications with the formula in the feeding bag (choice
D) can affect the feeding formula's composition and may lead to inaccurate dosing.
Question 4 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Cover the area of percussion with a towel. This is important to prevent skin irritation or discomfort during the procedure. The towel acts as a barrier between the client's skin and the nurse's hand, reducing friction and protecting the skin. Performing percussion directly on the skin can cause redness, bruising, or discomfort, so covering the area with a towel is a standard practice to ensure the client's safety and comfort.
Choice A is incorrect because percussion should be performed over specific areas of the chest, not the lower back.
Choice C is incorrect as postural drainage should be scheduled before meals to prevent aspiration.
Choice D is incorrect as clients should exhale slowly and relax during vibration to promote airway clearance.
Question 5 of 5
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply)
Correct Answer: A,B,D
Rationale: The correct answers are A, B, and D. A indicates understanding of fire safety, B shows awareness of medication safety, and D demonstrates knowledge of fall prevention. Option C is incorrect because setting the hot water heater to 140 degrees Fahrenheit is too hot and can cause burns. Option E is incorrect because taping over frayed electrical cords is not safe and can lead to electrical hazards.