ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?
Correct Answer: C
Rationale: Cranial nerve VI (abducens) controls the lateral rectus muscle enabling lateral eye movement. Asking the client to look outward assesses this function. Visual acuity (
A) whispering (
B) and smiling (
D) assess cranial nerves II VIII and VII respectively.
Question 2 of 5
A nurse administers 200 mL of enteral nutrition via a client's gastrostomy (GT) tube. The nurse flushes the feed bolus with 30 mL of water before and after the feed. How many mL does the nurse document as intake in the I&O?
Correct Answer: 260
Rationale:
Total intake = 200 mL (nutrition) + 30 mL (pre-flush) + 30 mL (post-flush) = 260 mL.
Question 3 of 5
A nurse is confirming with the client the informed consent signed earlier that day. The client then states, 'I have changed my mind and do not want to have the procedure done.' What action should the nurse take?
Correct Answer: B
Rationale: Notifying the surgeon respects the client’s autonomy to withdraw consent, allowing further discussion or cancellation. Consent is not legally binding, and proceeding or cancelling without surgeon input is inappropriate.
Question 4 of 5
A nurse is preparing to administer furosemide 4 mg via IV bolus to a client. The amount available is furosemide 10 mg/mL. How many mL should the nurse administer per dose (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.4
Rationale:
To administer 4 mg of furosemide (10 mg/mL) divide 4 mg by 10 mg/mL = 0.4 mL. The answer is not rounded to a whole number as 0.4 mL is precise for IV bolus administration. Use a leading zero (0.4) and avoid trailing zeros.
Question 5 of 5
A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status disorientation and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?
Correct Answer: D
Rationale: Delirium is characterized by sudden onset of confusion disorientation and hallucinations often triggered by acute conditions like a UTI in elderly clients. Sleep deprivation (
A) normal aging (
B) and dementia (
C) typically present with gradual or less acute symptoms.