ATI RN
ATI Fundamental Exams Questions
Extract:
Question 1 of 5
A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct
Answer: D - Determine the length of the NG tube to be inserted prior to the procedure.
Rationale: Before inserting an NG tube, the nurse must measure the distance from the client's nostril to the earlobe to the xiphoid process to determine the appropriate length of the tube to be inserted. This measurement helps ensure that the tube reaches the stomach without coiling in the esophagus or being too short to reach the stomach. Proper insertion depth minimizes the risk of complications such as aspiration or discomfort for the client.
Summary:
A: Asking the client to cough while inserting the NG tube is unnecessary and does not contribute to the safe insertion of the tube.
B: Sterile gloves are not required for NG tube insertion unless the client is immunocompromised or during specific circumstances.
C: Placing the client into a left lateral position is not a standard step for NG tube insertion and is not necessary in this scenario.
E, F, G: No information is provided for
Question 2 of 5
A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?
Correct Answer: A
Rationale: The correct answer is A: Cancer pain. Painful dermatitis resulting from radiation therapy in a client with cancer is categorized as cancer pain. This pain is directly related to the cancer and its treatment. Cancer pain can manifest as acute, chronic, or neuropathic pain depending on the underlying cause. In this case, the pain is directly associated with the cancer treatment and falls under the category of cancer pain. Other choices such as acute pain (
B), chronic pain (
C), and neuropathic pain (
D) may not accurately describe the pain experienced in this specific situation.
Question 3 of 5
A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations?
Correct Answer: B
Rationale: The correct answer is B: Hypervolemia. In end-stage kidney disease, the kidneys are unable to effectively regulate fluid balance, leading to fluid retention. The client's shortness of breath, lower extremity edema, crackles in the lungs, and elevated blood pressure are all indicative of fluid overload. Hypervolemia results from an excess of fluid in the intravascular space, causing symptoms such as pulmonary congestion (crackles in the lungs), peripheral edema, and hypertension. Hyponatremia (
A) would present with neurologic symptoms rather than respiratory and cardiovascular findings. Hypovolemia (
C) would manifest with hypotension and decreased urine output. Hyperkalemia (
D) would typically present with cardiac manifestations such as arrhythmias, muscle weakness, and ECG changes.
Question 4 of 5
A patient has been admitted for surgery for a colostomy. The patient states, 'I can’t believe this has happened to me.' What is the nurse’s best response?
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's feelings, provides reassurance about leading a normal lifestyle post-surgery, and opens up the opportunity for the patient to express their concerns. Option B focuses on the husband's reaction, which is not the patient's primary concern. Option C dismisses the patient's emotions and may come off as invalidating. Option D, while acknowledging the patient's disbelief, does not directly address the patient's concerns about the surgery.
Question 5 of 5
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can’t seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Correct Answer: C
Rationale: The correct answer is C: Encouraging the client to drink 2 to 3 L of water daily. Increasing fluid intake helps to thin bronchial secretions, making them easier to expectorate. This is especially important for clients with COPD who have difficulty clearing their airways. A low-salt diet (
A) is not directly related to managing bronchial secretions. Administering oxygen (
B) is important for COPD patients, but it does not specifically address the issue of thick secretions. Maintaining a semi-Fowler's position (
D) can help with breathing but does not directly address the issue of tenacious secretions.