ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice
A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice
C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice
D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
Question 2 of 5
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all.
Correct Answer: A, B, C
Rationale:
Correct
Answer: A, B, C
Rationale:
A: Auscultating bowel sounds is important to assess gastrointestinal motility and ensure the client is ready to receive the feeding.
B: Assisting the client to an upright position helps prevent aspiration during feeding by promoting proper tube placement.
C: Testing the pH of gastric aspirate confirms tube placement in the stomach and prevents potential complications from feeding into the lungs.
Summary:
D: Warming the formula is not necessary before administration and can lead to bacterial growth.
E: Discarding residual gastric contents should be done after assessing the pH, not before.
Question 3 of 5
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all.
Correct Answer: A, B
Rationale:
Correct
Answer: A, B
Rationale:
A: Review a signal the client can use if feeling any distress - This is important to ensure the client can communicate any discomfort or issues during the procedure.
B: Lay a towel across the client's chest - Helps protect the client's clothing and bedding from potential spillage during the procedure.
C: Administer oral pain meds - Not necessary prior to NG tube insertion for gastric decompression.
D: Obtain a Dobhoff tube for insertion - Dobhoff tube is not typically used for gastric decompression with NG tube.
E: Have a petroleum-based lubricant available - Lubricant is required for NG tube insertion but not specifically petroleum-based.
F:
G:
Summary:
Choices C, D, and E are not necessary prior to beginning the NG tube insertion procedure.
Choice A and B are essential steps to ensure patient safety and comfort during the process.
Question 4 of 5
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all.
Correct Answer: B, C
Rationale: The correct answers are B (Impaired circulation) and C (Impaired/suppressed immune system). Impaired circulation can lead to decreased oxygen and nutrient delivery to the wound site, hindering the healing process. In this case, the adolescent may have impaired circulation due to diabetes mellitus. An impaired/suppressed immune system can also delay wound healing by impairing the body's ability to fight off infection and promote tissue repair. The other options are not applicable in this scenario: A (Extremes in age) does not apply as the client is an adolescent; D (Malnutrition) is not indicated as the client is tolerating a regular diet; and E (Poor wound care) is not evident as the incision is well-approximated and free of redness, with only scant serous drainage.
Question 5 of 5
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include:
A) Increase in incisional pain: Infection can cause localized pain.
B) Fever & chills: Systemic signs of infection.
C) Reddened wound edges: Classic sign of wound infection. Incorrect choices:
D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.