ATI RN
ATI Nur 104 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is preparing to administer Ringer's lactate 500 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 56
Rationale: Calculation: (500 mL / 3 hr) / 60 min * 20 gtt/mL = 55.6 gtt/min, rounded to 56 gtt/min.
Question 2 of 5
A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?
Correct Answer: A
Rationale:
Tolerance, requiring higher doses for effect, is common with opioids like morphine. Improper use, confusion, or addiction lack evidence here.
Question 3 of 5
A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The deltoid accommodates <2 mL to prevent complications. A 22-25 gauge needle, 3-5 cm below the acromion, and 90° angle are standard, but volume is key.
Question 4 of 5
A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?
Correct Answer: B
Rationale: Diphenhydramine prevents urticaria (hives), a mild allergic reaction. Hemolysis, fever, and fluid overload are unrelated to antihistamines.
Question 5 of 5
A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Instilling water before and after each medication and after all medications ensures tube patency and prevents clogging. Water before aspiration interferes with residual checks, and slow flow requires tube assessment.