ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has returned to the unit following a surgical procedure of the abdomen. The client is complaining of pain 6/10. On assessment, the client's oxygen saturation is 85%. Which action should the nurse take first?
Correct Answer: D
Rationale: Administering oxygen at 2 L/min addresses the critical hypoxemia (85% saturation) to prevent further complications. Pain management and positioning follow after stabilizing oxygenation.
Question 2 of 5
A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?
Correct Answer: B
Rationale: Opioid overdose causes hypoventilation leading to CO2 retention and respiratory acidosis (low pH high PaCO2). Metabolic acidosis (
A) respiratory alkalosis (
C) and metabolic alkalosis (
D) are unrelated to hypoventilation.
Question 3 of 5
A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?
Correct Answer: B
Rationale: Gown and gloves prevent contact transmission of C. difficile. Masks are unnecessary, alcohol-based sanitizers are ineffective against spores, and blood tests don’t diagnose C. difficile.
Question 4 of 5
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?
Correct Answer: A
Rationale: Keeping the drainage system below chest level prevents backflow of fluid/air into the pleural space maintaining negative pressure. Clamping the tube (
B) risks tension pneumothorax emptying the chamber (
C) is unnecessary and disconnecting (
D) disrupts the system.
Question 5 of 5
A nurse administers 200 mL of enteral nutrition via a client's gastrostomy (GT) tube. The nurse flushes the feed bolus with 30 mL of water before and after the feed. How many mL does the nurse document as intake in the I&O?
Correct Answer: 260
Rationale:
Total intake = 200 mL (nutrition) + 30 mL (pre-flush) + 30 mL (post-flush) = 260 mL.