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: The correct answer is D: A gastric residual of 300 mL at the end of the shift. This finding is unexpected because a high residual volume may indicate feeding intolerance or delayed gastric emptying, which can lead to aspiration or other complications. Monitoring gastric residuals helps assess the client's tolerance to enteral feeding.
A: A weight gain of 0.91 kg (2 lb) in 2 days - This could be expected due to fluid retention or intake exceeding output.
B: A blood glucose level of 110 mg/dL - This is within normal range and not unexpected.
C: Diarrhea one time in a 24-hr period - Occasional diarrhea can occur with enteral feeding and is not necessarily unexpected.
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 planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?
Correct Answer: B
Rationale: The correct answer is B: Schedule the client as the first surgical procedure of the day. This is appropriate because scheduling the client as the first surgery reduces the risk of exposure to latex, as there will be less latex residue in the operating room. This minimizes the chances of an allergic reaction for the client.
A: Cleansing the stoppers with povidone-iodine does not directly address the latex allergy and does not prevent exposure to latex.
C: Removing the stopcocks from IV tubing may reduce latex exposure, but scheduling the client as the first procedure is more effective.
D: Ensuring that gloves in the surgical suite are powdered can actually increase the risk of allergic reactions as the powder can contain latex particles.
Therefore, choosing option B is the most appropriate and effective action to include in the client's plan of care.
Question 4 of 5
A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Keep the drainage bag below the level of the bladder. This is important to prevent backflow of urine into the bladder, reducing the risk of urinary tract infections. Placing the drainage bag below the level of the bladder ensures a continuous flow of urine out of the bladder and into the bag. Option B is incorrect as attaching the drainage bag to the side rails can cause tension on the catheter, leading to displacement or obstruction. Option C is incorrect as the drainage bag should be emptied when it is half-full to prevent backflow or infection. Option D is incorrect as taping the catheter to the lower abdomen can cause tension and discomfort.
Question 5 of 5
A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?
Correct Answer: C
Rationale:
Correct
Answer: C
Rationale:
1. "New dressing applied as prescribed" - This entry documents the action taken by the nurse, ensuring compliance with the care plan.
2. "No drainage on old dressing" - This indicates the status of the wound, showing that there is no abnormal discharge.
3. It provides specific and relevant information related to the dressing change, demonstrating thorough documentation.
Incorrect
Choices:
A: Irrelevant information about premedication with MSO, subq prior to dressing change.
B: Subjective assessment without concrete details or objective findings.
D: Lack of specific details or assessment of the wound's condition.
Overall, choice C provides clear, concise, and relevant information essential for accurate documentation.