ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
Correct Answer: A, B, C
Rationale: The correct answer includes guidelines A, B, and C. Placing the client in semi-Fowler's position allows for easier chest expansion. Having the client rest an arm across the abdomen helps to promote relaxation and allows for easier observation of respiratory movements. Observing one full respiratory cycle before counting the rate ensures an accurate assessment. Guidelines D and E are incorrect. Counting the rate for one minute is unnecessary if the rate is regular; it can be counted for 30 seconds and then doubled. Reporting sighs is not a standard practice in measuring respiratory rate and is not relevant to the assessment.
Question 2 of 5
A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of the PCA device. The client acknowledges the need to communicate with the nurse if pain persists after using the device, indicating awareness of the device's purpose and the importance of monitoring pain levels.
Choice A shows hesitation, which may delay effective pain management.
Choice B suggests fear of overdose but lacks understanding of the device's safety features.
Choice D poses a safety risk by involving an unauthorized person in medication administration.
Choices E, F, and G are irrelevant as they do not address the proper use of the PCA device.
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 preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve?
Correct Answer: D
Rationale: The correct answer is D: Carbohydrates. Carbohydrates are the body's priority energy reserve because they are easily broken down into glucose, which is the primary source of energy for the body's cells. When carbohydrates are consumed, they are converted into glycogen and stored in the muscles and liver for quick energy release. In contrast, fats are a more efficient long-term energy source, proteins are primarily used for tissue repair and growth, and glycogen is a short-term energy source stored in the muscles and liver.
Therefore, carbohydrates are the body's priority energy reserve for immediate energy needs.
Question 5 of 5
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Auscultating bowel sounds is important to ensure proper GI function before administering enteral feedings.
B: Assisting the client to an upright position helps prevent aspiration during feeding.
C: Testing the pH of gastric aspirate ensures the tube is correctly positioned in the stomach and not in the lungs.
Incorrect
Choices:
D: Warming the formula is not a necessary step prior to administering enteral feedings.
E: Discarding residual gastric contents is not typically done before administering enteral feedings unless there is a specific reason to do so.