ATI PN Fundamentals 2020 NGN Exam 1

Extract:

Question 1 of 5

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A. Clean the perineal area at least once a day. B. Empty the drainage bag when it is three-fourths full. C. Flush the catheter with sterile water daily. D. Disconnect the drainage bag when emptying and measuring urine.

Correct Answer: B

Rationale: Emptying the drainage bag when it is three-fourths full prevents backflow and reduces infection risk, making it the correct action for catheter care.

Question 2 of 5

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

A. Completion of an incident report. B. Name of the nurse certifying the client's death. C. Release of personal belongings form. D. One client identifier at the client's time of death.

Correct Answer: C

Rationale: The release of personal belongings form ensures proper accounting and handover of the client's belongings, providing a clear record essential for postmortem documentation.

Question 3 of 5

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

A. What types of foods have you been eating?' B. Are you using stool softeners or laxatives?' C. Have you been passing gas?' D. Have you had small liquid stools?'

Correct Answer: D

Rationale: Have you had small liquid stools?' is critical as small liquid stools can indicate fecal impaction, where liquid leaks around the impacted mass, making it the most direct question.

Question 4 of 5

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

A. Measure the client's gastric residual before each feeding. B. Change the bag and tubing every 24 hr. C. Document intake and output. D. Flush the tubing with 30 mL of water after each feeding.

Correct Answer: A

Rationale: Measuring gastric residual before each feeding assesses tolerance and prevents complications like aspiration, making it the priority action.

Question 5 of 5

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

A. Sharing the client's prognosis with a member of the client's family. B. Discussing the client's status with a member of the spiritual support team. C. Collaborating with a nurse from another unit about the client's care. D. Providing client information to another nurse at change of shift.

Correct Answer: D

Rationale: Providing information to another nurse at shift change is necessary for care continuity and is an appropriate disclosure within the healthcare team, maintaining confidentiality.

ATI PN Fundamentals 2020 NGN Exam 1 | Nurselytic

Nurselytic

ATI LPN

ATI LPN