ATI RN Fundamentals 2023 I

Extract:

Question 1 of 5

A nurse is preparing to administer intermittent tube feeding to a client who has a percutaneous gastrostomy tube. Which of the following actions should the nurse take?

A. Check the pH level of the client’s gastric contentsB. Check the patency of the client’s tube every 8 hrC. Place the client in a supine positionD. Flush the client’s tube with 5 mL of water

Correct Answer: D

Rationale: Flushing with 5 mL water maintains patency and clears residue. pH checks are for NG tubes, 8-hour checks are too infrequent, and supine positioning risks aspiration—semi-upright is preferred.

Question 2 of 5

A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

A. Uses one pair of gloves for dressing removal and irrigationB. Uses a syringe with a catheter for wound irrigationC. Administers an analgesic medication 5 min before starting irrigationD. Refrigerates the solution before irrigation

Correct Answer: B

Rationale: A syringe with a catheter provides controlled irrigation, cleaning the wound effectively. One pair of gloves risks contamination, 5-min analgesia is too short, and cold solution causes discomfort.

Question 3 of 5

A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

A. Apply the pouch while the skin barrier is still dampB. Change the pouch once every 24 hrC. Rub the peristomal skin dry after cleaningD. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma

Correct Answer: D

Rationale: A pouch 1/8 inch larger than the stoma prevents irritation and ensures a secure fit. Damp skin barriers reduce adhesion, daily changes may irritate skin, and rubbing can damage peristomal skin—patting dry is preferred.

Question 4 of 5

A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A. Ensure that the client’s bed is in the lowest positionB. Assess skin temperature and color before applying the restraintsC. Attach the client’s restraints to the bed railD. Pad bony prominences before applying the restraintsE. Secure restraints to allow three fingers to slide under the restraints

Correct Answer: A,B,D

Rationale: A: Low bed prevents falls. B: Assessing skin ensures circulation. D: Padding prevents pressure injuries. C: Bed rails risk injury—use bed frame. E: Three fingers is too loose—two is standard.

Question 5 of 5

A nurse is planning to administer insulin to a client who has type 1 diabetes mellitus, what action should the nurse perform first?

A. Administer the client’s insulin dose using a tuberculin syringeB. Use a filter needle when withdrawing medication from the multidose vialC. Verify the dose of insulin with another nurse once it is preparedD. Mix the client’s long-acting and rapid-acting insulin dose in one syringe

Correct Answer: C

Rationale: Verifying the dose with another nurse ensures accuracy, preventing errors in this high-risk medication. Administering, using a filter needle, or mixing come after confirmation.

ATI RN Fundamentals 2023 I | Nurselytic

Nurselytic

ATI RN

ATI RN