ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Extract:
Question 1 of 5
A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?
Correct Answer: C
Rationale: Cyanotic digits indicate impaired circulation due to tight restraints requiring immediate loosening to prevent tissue damage. Full range of motion (
A) and no discomfort (
D) suggest adequate restraint fit while attempting to remove them (
B) requires monitoring not loosening.
Question 2 of 5
A nurse administers 200 mL of enteral nutrition via a client's gastrostomy (GT) tube. The nurse flushes the feed bolus with 30 mL of water before and after the feed. How many mL does the nurse document as intake in the I&O?
Correct Answer: 260
Rationale:
Total intake = 200 mL (nutrition) + 30 mL (pre-flush) + 30 mL (post-flush) = 260 mL.
Question 3 of 5
A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?
Correct Answer: C
Rationale: Lift pads reduce friction/shearing during repositioning preventing skin damage. Staff injury prevention (
A) incontinence management (
B) and diaphoresis (
D) are not primary purposes.
Question 4 of 5
A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:
Correct Answer: B
Rationale: Taking medication with a full glass of water ensures proper absorption and reduces esophageal irritation. The other options are incorrect as they depend on specific medication requirements or falsely assume side effects like abdominal pain.
Question 5 of 5
A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?
Correct Answer: A
Rationale: Rubbing soap on hands for at least 20 seconds ensures thorough cleaning of all hand surfaces, as recommended by the CDC. Drying is important but secondary, holding hands higher is for surgical antisepsis, and hot water is unnecessary as warm or cold water is effective.