ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Extract:
Question 1 of 5
A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy?
Correct Answer: B
Rationale: The cephalic vein in the left distal forearm is appropriate, as IVs should be placed on the opposite side of a mastectomy to avoid lymphedema risk. Right-sided veins and the radial vein are less suitable. The median vein in the right forearm is also incorrect due to lymphedema risk.
Question 2 of 5
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Placing the shallow end of the fracture bedpan under the buttocks ensures proper positioning and comfort for an immobile client. Hyperextending the back causes discomfort, 20 minutes is excessive, and a slightly elevated head may aid defecation. Applying lubricant is unnecessary and may cause slippage.
Question 3 of 5
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
Correct Answer: C
Rationale: Emptying the reservoir is the appropriate action because a Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied. The bulb should be emptied before it is more than half full to prevent complications such as hematoma formation, infection, drain occlusion, and delayed wound healing. Leaving it until the end of the shift risks these complications. Removing the drain without a surgeon's order could disrupt healing, and notifying the surgeon is not necessary unless there are signs of excessive bleeding (e.g., bright red blood, clots, or drainage >100 ml in 24 hours). Applying pressure to the drain site is incorrect as it does not address the reservoir’s function and could disrupt the drain’s placement.
Question 4 of 5
How should the nurse record the net fluid intake for a client who received 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization?
Correct Answer: D
Rationale:
Total intake: 600 mL (sodium chloride) + 100 mL (cefazolin) = 700 mL.
Total output: 200 mL (emesis) + 40 mL (voided urine) + 20 mL (catheterized urine) = 260 mL. Net fluid intake: 700 mL - 260 mL = 440 mL. 700 mL is incorrect, as it represents gross intake, not net.
Question 5 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: B
Rationale: Aspirating residual volume every 4 hours ensures the client tolerates feedings and prevents overfeeding or aspiration. Tubing should be changed every 24 hours, flushing requires 30 mL every 4-6 hours, and formula should be at room temperature. Bolus feeding is inappropriate for continuous feedings.