ATI PN Fundamentals Updated 2023

Extract:

Question 1 of 5

A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider?

A. Greenish-yellow drainage B. Report of hunger C. Gastric contents are present in the air vent D. Abdominal distention

Correct Answer: C

Rationale: Gastric contents in the air vent indicate that the NG tube is clogged or kinked, which can lead to aspiration or infection, and should be reported. Greenish-yellow drainage and hunger are normal, and abdominal distention should improve with decompression.

Question 2 of 5

A nurse is caring for a client who speaks a different language than the nurse and is 5 hours postoperative. Which of the following actions should the nurse take to determine the client's level of pain?

A. Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level. B. Ask an assistive personnel who speaks the same language as the client to interpret. C. Use a communication board to interact with the client. D. Use the FACES pain scale to gauge the client's level of pain.

Correct Answer: C

Rationale: Using a communication board is an effective way to assess the client's pain level and location, overcoming the language barrier. The FLACC scale is for infants/children, AP interpretation is unreliable, and the FACES scale may not be culturally understood.

Question 3 of 5

A nurse is reinforcing teaching with a client who has a new Westerly syndrome. Which of the following statements by the client demonstrates an understanding of the teaching?

A. I can eat broccoli as a snack. B. I should avoid bananas in my diet. C. I can have mushrooms on my pizza. D. I need to limit popcorn intake.

Correct Answer: B

Rationale: Bananas are high in potassium, which can affect heart rhythm and should be avoided with Westerly syndrome. Broccoli should be moderated due to vitamin C, mushrooms are safe, and popcorn's sodium content should be limited.

Question 4 of 5

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

A. Stand on the client's stronger side when moving the client into the chair. B. Raise the bed to waist level before moving the client. C. Flex hips and knees when assisting the client to a standing position. D. Pivot on the foot farthest from the bed when assisting the client into the chair.

Correct Answer: C

Rationale: Flexing hips and knees helps the client use their stronger leg muscles and maintain balance. Standing on the stronger side, raising the bed too high, or pivoting incorrectly can increase fall risk.

Question 5 of 5

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

A. A client reports being dissatisfied with the temperature of the meals provided. B. A client receives burns from a heating pad. C. A client becomes disoriented and falls out of bed. D. A client is unable to afford the physical therapy that the provider recommends. E. A client's visitor's getting dizzy and fainting in the client's room

Correct Answer: B,C,E

Rationale: Burns from a heating pad, a fall due to disorientation, and a visitor fainting are incidents requiring reports due to injury or unexpected events. Meal dissatisfaction and affordability issues do not typically warrant incident reports.

ATI PN Fundamentals Updated 2023 | Nurselytic

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