ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Extract:
Question 1 of 5
A nurse is reviewing the medical record of a newly admitted client. Which of the following laboratory values should the nurse report to the provider?
Correct Answer: A
Rationale: Potassium 5.8 mEq/L is above the normal range (3.6–5.2 mEq/L) and indicates hyperkalemia, which can cause cardiac arrhythmias and requires immediate reporting. Sodium (135–145 mEq/L), magnesium (1.7–2.2 mEq/L), and calcium (8.5–10.2 mg/dL) values are within normal ranges. Glucose 110 mg/dL is normal and does not require reporting.
Question 2 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 3 of 5
A nurse is caring for a client who is restrained to each extremity. Which of the following assessments should the nurse perform first?
Correct Answer: D
Rationale: Assessing peripheral pulses first ensures that restraints are not compromising circulation, which could lead to tissue damage. Elimination, comfort, skin integrity, and respiratory status are important but secondary to circulation.
Question 4 of 5
A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?
Correct Answer: C
Rationale: Wearing a mask when outside the room is crucial for a client undergoing an allogeneic stem cell transplant due to their immunocompromised state, protecting against infections. Visitors wearing gowns is secondary, semi-private rooms are avoided to reduce infection risk, and negative-airflow rooms are used to protect others, not the patient. Daily antibiotics are not standard unless infection is present.
Question 5 of 5
A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first?
Correct Answer: D
Rationale: Determining whether the client can afford insulin supplies ensures access to necessary treatment, preventing non-compliance. Other actions (reconciliation form, education materials, specialist contact, follow-up appointment) follow once affordability is confirmed.