ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
Correct Answer: B
Rationale:
Correct Answer: B - Verify the placement of the NG tube.
Rationale: Ensuring proper NG tube placement is crucial before administering enteral feedings to prevent complications such as aspiration. The nurse should confirm the tube's position by checking for gastric aspirate pH or using an X-ray. This step is essential for the client's safety.
Incorrect
Choices:
A: Checking the feeding container's duration is important for assessing feeding integrity but not as critical as verifying tube placement.
C: Diarrhea assessment is important for monitoring the client's gastrointestinal status but does not take precedence over tube placement verification.
D: Client's alertness and orientation are vital for overall assessment but not directly related to enteral feeding safety.
Question 2 of 5
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
Correct Answer: A, D, E
Rationale: The correct guidelines for endotracheal suctioning are A, D, and E. A is correct because applying suction while withdrawing the catheter helps prevent trauma to the airway. D is correct to prevent the risk of infection by using a new catheter for each suctioning attempt. E is correct to limit the number of suctioning attempts to prevent hypoxia and airway trauma.
Choice B is incorrect as suctioning should be based on assessment rather than routine timing.
Choice C is incorrect as strict sterile technique, not just medical asepsis, is required for suctioning.
Question 3 of 5
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
Correct Answer: C
Rationale: The correct answer is C. The nurse may assign the task of reapplying a condom catheter for a client who has urinary incontinence to assistive personnel (AP). This task involves a routine procedure that does not require specialized nursing knowledge or assessment skills. It is a straightforward task that can be safely delegated to AP under the supervision of the nurse.
Choices A, B, and D involve more complex care that requires nursing assessment, critical thinking, and specialized skills. Feeding a client with aspiration pneumonia requires monitoring for signs of aspiration, reinforcing teaching about using a quad cane involves patient safety and proper technique, and applying a sterile dressing to a pressure ulcer requires aseptic technique to prevent infection. These tasks should be performed by the nurse to ensure the safety and well-being of the clients.
Question 4 of 5
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. Linear clusters of vesicles with crusting are classic symptoms of herpes zoster, also known as shingles, caused by the reactivation of the varicella-zoster virus. The linear distribution follows the nerve pathways affected by the virus. This presentation is distinct from an allergic reaction (
A), which typically manifests as hives or red, itchy skin patches. Ringworm (
B) presents as circular, scaly patches and is caused by a fungus, not a virus like herpes zoster. Systemic lupus erythematosus (
C) is an autoimmune disease that does not typically present with linear clusters of vesicles.
Question 5 of 5
A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all.
Correct Answer: A, B
Rationale:
Correct Answer: A, B
Rationale:
A: Making sure the surgeon obtained the client's consent is crucial to ensure that the client has been properly informed about the procedure and has voluntarily agreed to it.
B: Witnessing the client's signature on the consent form is important as it verifies that the client has personally agreed to the procedure after understanding the risks and benefits.
C: While explaining the risks and benefits of the procedure is important, this task is typically performed by the healthcare provider or surgeon, not the nurse providing preop care.
D: Describing the consequences of choosing not to have the surgery is important, but it is usually the responsibility of the healthcare provider or surgeon, not the nurse providing preop care.
E: Informing the client about alternatives to having the surgery is important, but this task is typically performed by the healthcare provider or surgeon, not the nurse providing preop care.
F: No information provided.
G: No information provided.
Summary:
The correct actions for