ATI RN
ATI RN Fundamentals Updated 2023 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: D
Rationale: A gastric residual of 300 mL (
D) is an unexpected finding, indicating delayed gastric emptying, which increases the risk of aspiration and requires stopping the feeding and notifying the provider. A weight gain of 0.91 kg in 2 days (
A) is expected, reflecting nutritional intake. A blood glucose level of 110 mg/dL (
B) is normal. Diarrhea once in 24 hours (
C) is a common side effect of enteral feeding and not immediately concerning unless persistent.
Question 2 of 5
A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: A sponge bath with alcohol-water solution (
C) promotes heat loss through evaporation, effectively reducing fever. A blanket with a cooling blanket (
A) reduces its effectiveness. Heavy blankets (
B) trap heat, worsening fever. Ice packs (
D) cause vasoconstriction, limiting heat loss and risking tissue damage.
Question 3 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Cleansing the stoma with normal saline (
B) prevents infection and maintains skin integrity. Cotton tip applicators (
A) risk leaving fibers, causing irritation. Soaking in tap water (
C) risks contamination; sterile solutions are preferred. Securing ties for one finger (
D) is correct but not the primary action compared to stoma care.
Question 4 of 5
A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps.
Correct Answer: A,B,C,E,D
Rationale: The sequence A,B,C,E,D follows the standard abdominal assessment: inspection (
A) first, then auscultation (
B) to avoid altering sounds, percussion (
C) to assess organ size, light palpation (E) for tenderness, and deep palpation (
D) last to avoid pain.
Question 5 of 5
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Exposing the abdomen (
D) is the first step to visually assess for complications like wound dehiscence or infection, which could explain severe pain. Listening for bowel sounds (
A) and percussion (
C) are part of a full assessment but not urgent. Palpation (
B) risks worsening pain or disrupting the wound and should be avoided initially.