ATI RN Fundamentals Updated 2023 Exam | Nurselytic

Correct Answer: A,B,C,E,D

Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.

The correct sequence for performing a physical assessment of a client's abdomen involves the following steps:
1. Provide adequate lighting to inspect the abdomen (Action
A) to ensure clear visibility.
2. Listen to the abdominal arteries using the bell of a stethoscope (Action
B) to assess vascular sounds.
3. Percuss all four quadrants of the abdomen (Potential Condition
C) to measure sound quality and identify any abnormalities.
4. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen (Parameter to Monitor E) to assess for pain or discomfort.
5. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen (Parameter to Monitor
D) to assess organ size and position.

This sequence ensures a systematic and comprehensive assessment of the abdomen,

Correct Answer: D

Rationale: The correct answer is D: A gastric residual of 300 mL at the end of the shift. This finding is unexpected because a high residual volume may indicate feeding intolerance or delayed gastric emptying, which can lead to aspiration or other complications. Monitoring gastric residuals helps assess the client's tolerance to enteral feeding.

A: A weight gain of 0.91 kg (2 lb) in 2 days - This could be expected due to fluid retention or intake exceeding output.
B: A blood glucose level of 110 mg/dL - This is within normal range and not unexpected.
C: Diarrhea one time in a 24-hr period - Occasional diarrhea can occur with enteral feeding and is not necessarily unexpected.

Correct Answer: C

Rationale: The correct answer is C: Obtain the client's vital signs. This is the first action the nurse should take because administering a larger IV fluid bolus than prescribed can potentially lead to adverse effects such as fluid overload or electrolyte imbalances. By obtaining the client's vital signs, the nurse can assess for any immediate signs of complications, such as changes in blood pressure, heart rate, or respiratory rate. This immediate assessment is crucial in ensuring the client's safety and well-being.

Other choices are incorrect:
A: Documenting the fluid infusion is important, but not the first priority in this situation.
B: Completing an incident report should be done after addressing the immediate needs of the client.
D: Reporting the incident to the unit manager is important, but not before ensuring the client's immediate safety.

Correct Answer: C

Rationale: The correct answer is C: "I will wear an N95 respirator mask when caring for the client." This is the correct choice because MRSA can be transmitted through respiratory droplets, and wearing an N95 respirator mask can help prevent the spread of the infection. Removing the gown before gloves (choice
A) is incorrect as it increases the risk of contamination. Asking visitors to wear a mask (choice
B) may be helpful but does not directly address the nurse's protection. Placing the client in a private room (choice
D) is important for isolation but does not focus on the nurse's protection.

Correct Answer: B

Rationale: The correct answer is B: Dilute each crushed medication with sterile water. This is the correct action because medications administered via NG tube should be in liquid form to prevent clogging and ensure proper absorption. Diluting each crushed medication with sterile water helps maintain the medication's consistency and facilitates its passage through the tube. Mixing medications together in a single syringe (choice
A) may cause interactions or alter the effectiveness of the medications. Flushing the NG tube with sterile water (choice
C) is important but not directly related to administering medications. Combining medications with the formula in the feeding bag (choice
D) can affect the feeding formula's composition and may lead to inaccurate dosing.