ATI RN
ATI Fundamentals Exam East Wick College Questions
Extract:
Question 1 of 5
A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Urine output 20 mL/hr. In dehydration, the body conserves fluid by decreasing urine output, leading to concentrated urine. This is a compensatory mechanism to maintain fluid balance. Bradycardia (
B) is not a typical finding in dehydration; tachycardia is more common due to decreased blood volume. Sodium levels (
C) may be elevated in dehydration due to hemoconcentration. Cool skin (
D) is a sign of decreased perfusion, not dehydration.
Question 2 of 5
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
Correct Answer: D
Rationale: The correct answer is D: Test the pH of gastric aspirate. Testing the pH of gastric aspirate is essential prior to administering enteral feedings via an NG tube to ensure proper tube placement in the stomach and avoid potential complications like aspiration pneumonia. A pH of 1-5 indicates gastric placement.
A: Assisting the client to low Fowler's position is important for comfort but not a critical step before administering tube feeding.
B: Warming the feeding solution to body temperature may enhance tolerance but is not a priority before checking the tube placement.
C: Discarding residual gastric contents is not necessary if the pH test confirms correct tube placement.
E, F, G: These choices are not relevant to the immediate pre-administration steps for enteral feedings.
Question 3 of 5
A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct response is C: Blood. A guaiac test detects the presence of occult (hidden) blood in the stool, which may indicate gastrointestinal bleeding. Lipids (
A), bacteria (
B), and bile (
D) are not typically detected by a guaiac test. Blood in the stool is a key indicator of various gastrointestinal conditions, making it the appropriate response in this context.
Question 4 of 5
A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Headache. A sodium level of 128 mEq/L indicates hyponatremia, which can lead to neurological symptoms like headache due to cerebral edema. Constipation (choice
A) is not typically associated with hyponatremia. Hyporeflexia (choice
B) is more indicative of hypernatremia. Increased appetite (choice
C) is not a common manifestation of hyponatremia.
Therefore, the correct choice is D as it aligns with the expected symptom of hyponatremia.
Question 5 of 5
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
Correct Answer: B
Rationale: The correct answer is B:
To identify delayed gastric emptying. Measuring gastric residual helps assess how much of the previous feeding remains in the stomach, indicating delayed emptying. This information is crucial for adjusting feeding rates to prevent complications like aspiration.
Choice A is incorrect as measuring gastric residual is not for removing gastric acid.
Choice C is incorrect as confirming NG tube placement is done through other methods like X-ray.
Choice D is incorrect as measuring gastric residual does not directly determine the client's electrolyte balance.