ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
Correct Answer: A, D
Rationale: Correct Answer Explanation: A nurse should keep the head of the bed elevated at 30 degrees to reduce pressure on the sacrum and coccyx, thus preventing pressure ulcers. Having the client sit on a gel cushion when in a chair helps distribute weight evenly and reduce pressure points. These interventions promote skin integrity by minimizing pressure and friction. Massage of bony prominences can increase the risk of pressure ulcers by causing friction and compromising blood flow. Applying cornstarch can create a moist environment, which can lead to skin breakdown. Repositioning the client at least every 3 hours helps to prevent pressure ulcers by relieving pressure points.
Question 2 of 5
A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk medication for the control of seizures. Which of the following statements by the nurse is appropriate?
Correct Answer: A
Rationale: The correct answer is A because Category D medications are known to have a risk of harm to the fetus. It is important for the nurse to inform the client about the potential adverse effects to the fetus.
Choice B is incorrect because Category D medications are not considered safe during pregnancy.
Choice C is incorrect because it oversimplifies the decision-making process by only considering risk versus benefit.
Choice D is incorrect because the lack of studies in pregnant women does not guarantee safety.
Question 3 of 5
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
Correct Answer: B
Rationale:
Correct Answer: B - Verify the placement of the NG tube.
Rationale: Ensuring proper NG tube placement is crucial before administering enteral feedings to prevent complications such as aspiration. The nurse should confirm the tube's position by checking for gastric aspirate pH or using an X-ray. This step is essential for the client's safety.
Incorrect
Choices:
A: Checking the feeding container's duration is important for assessing feeding integrity but not as critical as verifying tube placement.
C: Diarrhea assessment is important for monitoring the client's gastrointestinal status but does not take precedence over tube placement verification.
D: Client's alertness and orientation are vital for overall assessment but not directly related to enteral feeding safety.
Question 4 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 answer is A, B, C. A postop wound infection typically presents with increased incisional pain (
A), fever & chills (
B), and reddened wound edges (
C). Pain may be due to inflammation caused by the infection. Fever and chills are systemic signs of infection. Reddened wound edges indicate inflammation and possible infection spreading.
Choices D and E are incorrect as increased serosanguineous drainage (
D) may be seen in the normal healing process, and a decrease in thirst (E) is not typically associated with wound infection.
Question 5 of 5
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him?
Correct Answer: D
Rationale:
Correct Answer: D (Social worker)
Rationale: The social worker is the most appropriate referral for the older adult facing difficulty in preparing nutritious meals. Social workers can assess the client's social needs, such as access to community resources, meal delivery services, or support groups. They can also help with financial assistance or other social services to ensure the client's well-being.
Summary of other choices:
A: Registered dietitian - While a dietitian can provide nutritional guidance, the client's issue is not solely about dietary recommendations but also about access to nutritious meals.
B: Occupational therapist - OTs focus on assisting clients with daily living activities and functional independence, not specifically addressing the client's meal preparation concerns.
C: Physical therapist - PTs focus on rehabilitation and physical function, not directly related to the client's nutritional challenges.