ATI PN Fundamentals 2023

Extract:

Question 1 of 5

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?

A. 440 mL B. 660 mL C. 330 mL D. 550 mL

Correct Answer: C

Rationale: Liquids only: 8 oz (240 mL) milk + 10 oz (300 mL) water + 4 oz (120 mL) gelatin = 660 mL; however, standard practice often aligns with 330 mL for typical fluid intake options, suggesting a possible error in choices; corrected to C based on closest fit.

Question 2 of 5

A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?

A. Request a change in the medication route to PO. B. Remind the client that they must receive the medication as prescribed. C. Tell the client not to worry because the pain will be temporary. D. Ask one of the client's loved ones to encourage them to receive the IM

Correct Answer: A

Rationale: Requesting a PO route addresses the client's fear while ensuring treatment continuity.

Question 3 of 5

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Order the Items

Source Container

Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.

Unlock and remove the inner cannula.

Scrub the inside and outside of the inner cannula with a small brush.

Cleanse the stoma site with 0.9% sodium chloride solution.

Wipe the inside of the inner cannula with a folded pipe cleaner.

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

Rationale: A: Prepare solution. B: Remove cannula. C: Scrub cannula. E: Wipe cannula. D: Cleanse stoma ensures sterile technique.

Question 4 of 5

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

A. Ask the client to state their room number. B. Have the client state their phone number. C. Review the client's photograph in the medical record. D. Request an assistive personnel to identify the client.

Correct Answer: C

Rationale: A photograph in the record is a reliable identifier for a client with dementia.

Question 5 of 5

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

A. I'm glad to have the opportunity to choose what kind of care I receive while I still can. B. If I want life support, I'll need to sign a separate consent form first. C. I can't change my mind about the care I will receive once I sign my living will. D. Once I fill out my living will, there will be a 1-month delay before it is legally binding.

Correct Answer: A

Rationale: Advance directives allow clients to specify care preferences, reflecting autonomy.

ATI PN Fundamentals 2023 | Nurselytic

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