ATI RN
ATI RN VATI Fundamentals S 2019 Final Questions
Extract:
Question 1 of 5
A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile,saline-soaked dressing which of the following actions should the nurse take?
Correct Answer: C
Rationale: Preparing the client for emergency surgery is critical as evisceration is a surgical emergency requiring immediate intervention to repair the wound and secure exposed organs. Lying flat may increase pressure on organs increasing risk. Increasing fluid intake is not a priority in this acute situation. Applying pressure could damage exposed organs and is contraindicated.
Question 2 of 5
A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: Sitting for 60 seconds prevents orthostatic hypotension ensuring safe ambulation. Walking on the right side is incorrect (should be left) looking down risks falls and the gait belt goes around the waist not chest.
Question 3 of 5
A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?
Correct Answer: A
Rationale: The 30° lateral position distributes weight evenly reducing pressure on bony prominences. Semi-prone supine and Fowler’s positions increase pressure on areas like the sacrum and heels heightening pressure injury risk.
Question 4 of 5
A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.)
Correct Answer: A,C,D,E
Rationale: Measuring aspirate amount examining secretion color measuring pH and obtaining an x-ray confirm NG tube placement. Flushing with water does not verify placement and may skew assessments.
Question 5 of 5
A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Slowly instilling 400 to 500 mL of solution effectively flushes the bladder without overdistension. Clamping the tubing prevents solution flow using a needle is inappropriate and withdrawing solution disrupts the irrigation process.