ATI RN
ATI RN Fundamentals Exam 6 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following nursing interventions is appropriate?
Correct Answer: A
Rationale: Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever. Encouraging increased fluid intake is appropriate to promote hydration but the specific amount should be individualized based on the client's condition and needs. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.
Question 2 of 5
A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?
Correct Answer: A
Rationale: Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls. Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention. Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate. Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.
Question 3 of 5
A guard at a prison brings an injured inmate to the facility clinic. The inmate is bleeding and the guard asks the nurse about the inmate's HIV infection status. Which of the following actions by the nurse is appropriate?
Correct Answer: C
Rationale: Having the guard sign a release of information form may not be appropriate in an emergency situation and immediate action is needed to address the injury. Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency. Completing an incident report is appropriate to document the situation and the care provided. It is not necessary to disclose the inmate's HIV status in the report. Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.
Question 4 of 5
A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?
Correct Answer: C
Rationale: Raising the index finger is not a typical response for managing gagging during NG tube insertion. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
Question 5 of 5
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1200 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero is applicable. Do not use a trailing zero.)
Correct Answer: 150
Rationale: The formula for the infusion rate is: (volume in mL / time in hours) x drop factor in gtts/mL = infusion rate in gtts/min. The drop factor is usually given on the IV tubing package and varies depending on the type of tubing used. For this question we can assume a drop factor of 15 gtts/mL which is common for macrodrip tubing. Plugging in the numbers we get: (1200 mL / 8 hr) x 15 gtts/mL = 2250 gtts/hr.
To convert from gtts/hr to mL/hr we divide by the drop factor: 2250 gtts/hr / 15 gtts/mL = 150 mL/hr.
Therefore the nurse should set the IV pump to deliver 150 mL/hr.