ATI RN
ATI RN Fundamentals 2019 II Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?
Correct Answer: D
Rationale: The correct answer is D: Present information about the benefits of quitting smoking. During the contemplation stage of health behavior change, the client is considering making a change but may still have ambivalence. Providing information about the benefits of quitting smoking can help the client explore the advantages of changing their behavior. This can help increase the client's motivation and readiness to move towards action.
A: Recommend small changes for the client to make to change her behavior over time - This may be more suitable for the preparation or action stages, not contemplation.
B: Assist the client in setting goals to make the change - Goal-setting is more appropriate for the preparation or action stages.
C: Develop a plan for the client to integrate the change into her lifestyle - Planning typically occurs in the preparation stage when the client is ready to take action.
Question 2 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: D
Rationale: The correct answer is D: A gastric residual of 300 mL at the end of the shift. This finding is unexpected because a high gastric residual volume may indicate delayed gastric emptying or intolerance to enteral feeding, which can lead to complications such as aspiration or malnutrition. A weight gain (choice
A) is expected due to caloric intake. Blood glucose of 110 mg/dL (choice
B) is within normal range. Diarrhea once (choice
C) can occur with enteral feeding but is not unexpected. In summary, a high gastric residual volume is concerning and requires further assessment and intervention.
Question 3 of 5
A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Flush the tubing with 10 mL of water every 2 hr. Flushing the tubing with water helps prevent clogs and maintains tube patency, ensuring proper delivery of the enteral feed. Regular flushing also reduces the risk of infection and keeps the tube clean. Heating the formula (choice
A) can alter its composition and cause burns. Aspirating residual volume (choice
B) is outdated practice and can lead to inaccurate readings. Changing the tubing set every 72 hr (choice
D) is not necessary unless there are signs of contamination or malfunction.
Question 4 of 5
A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?
Correct Answer: B
Rationale: The correct answer is B: Schedule the client as the first surgical procedure of the day. This is appropriate because scheduling the client as the first procedure reduces the risk of latex exposure from previous procedures. Latex particles can linger in the air and on surfaces, increasing the risk of a reaction for a latex-allergic client.
Choice A is incorrect because cleansing stoppers with povidone-iodine does not address the risk of latex exposure during surgery.
Choice C is incorrect as removing stopcocks from IV tubing may not eliminate all sources of latex exposure.
Choice D is incorrect because powdered gloves can increase the risk of latex exposure and should be avoided for a latex-allergic client.
Question 5 of 5
A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Keep the drainage bag below the level of the bladder. This is crucial to prevent backflow of urine into the bladder, reducing the risk of urinary tract infections. Placing the bag below the bladder allows gravity to assist in drainage.
Choice B is incorrect as attaching the bag to the side rails can cause tension on the catheter leading to displacement or obstruction.
Choice C is incorrect because waiting for the bag to be three-quarters full can increase the risk of infection.
Choice D is incorrect as taping the catheter to the lower abdomen can cause pressure ulcers and restrict urine flow.