ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Question 1 of 5
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is important because when using an open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to ensure accurate monitoring of urine output. By subtracting the amount of irrigant used from the total urine output, the nurse can accurately assess the client's true urine output.
Choice A is incorrect because placing the client in a semi-lying position is not directly related to the irrigation technique.
Choice B is incorrect as instilling a specific amount of 15 mL of irrigation fluid with each flush is not a standard practice for open irrigation technique.
Choice D is incorrect as the size of the syringe used for irrigation is not specified in standard guidelines.
Question 2 of 5
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Administer the medication to the abdomen. When self-administering heparin, the abdomen is the recommended site due to its larger subcutaneous tissue and slower absorption, reducing the risk of hematoma formation and irritation. Administering heparin in the abdomen also allows for consistent absorption and avoids potential complications from injecting in areas with higher vascularity.
Choices A, B, and D are incorrect because stirring the needle, aspirating the syringe, and massaging the site are not recommended practices for administering heparin. These actions can increase the risk of bruising, bleeding, or tissue damage. It is important to follow evidence-based guidelines for safe and effective medication administration.
Question 3 of 5
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
Correct Answer: D
Rationale:
Correct Answer: D - Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Rationale: Having the client take sips of water helps facilitate the passage of the NG tube through the esophagus by promoting swallowing reflexes and lubricating the tube. This method is commonly used to aid in the insertion process and reduce discomfort for the client.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important for NG tube insertion but not the direct action needed during insertion.
B: Removing the NG tube if the client gags or chokes is incorrect; these are common reactions during insertion and do not necessarily indicate a problem.
C: Applying suction to the NG tube prior to insertion is unnecessary and can cause discomfort or injury to the client.
Question 4 of 5
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 107
Rationale:
To calculate the infusion rate, divide the total volume to be infused (750mL) by the total time in hours (7 hours). 750mL / 7 hours = 107 mL/hr. This is the correct answer as it determines the rate at which the solution should be administered to ensure the correct dosage is delivered over the specified time. Other choices are incorrect as they do not result from the correct calculation method, which is essential in determining the appropriate infusion rate for the patient.
Question 5 of 5
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale:
Correct Answer: A: Insert the catheter at a 45-degree angle.
Rationale: Inserting the catheter at a 45-degree angle is appropriate for older adults as their skin may be more fragile, reducing the risk of tissue damage. This angle also helps in successful IV insertion by facilitating cannulation of the vein.
Summary of other choices:
B: Placing the client's arm in a dependent position does not directly impact the IV catheter insertion process.
C: Shaving excess hair is unnecessary and may increase the risk of skin irritation and infection.
D: Initiating IV therapy in the veins of the hand is not specific to the insertion technique and does not address the angle of insertion.