ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Extract:
A nurse is caring for a client. Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6°C (99.7°F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5°C (99.5°F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air
Question 1 of 5
Select the 4 findings that require immediate follow-up.
Correct Answer: B,D,E
Rationale: The findings requiring immediate follow-up are blood pressure (significant drop from 108/56 to 88/56 mm Hg, indicating possible hypotension), pulse oximetry (decrease from 97% to 93%, suggesting reduced oxygen saturation), heart rate (increase from 66/min to 104/min, indicating tachycardia), and level of consciousness (always critical to monitor for changes in clinical status). Temperature and respiratory rate changes are within normal ranges, and skin color/temperature data is not provided. Skin color and temperature do not require immediate follow-up without specific abnormal findings.
Extract:
Question 2 of 5
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Placing the shallow end of the fracture bedpan under the buttocks ensures proper positioning and comfort for an immobile client. Hyperextending the back causes discomfort, 20 minutes is excessive, and a slightly elevated head may aid defecation. Applying lubricant is unnecessary and may cause slippage.
Question 3 of 5
A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of the following individuals should sign the consent form?
Correct Answer: D
Rationale: The infant’s 17-year-old mother, as the parent, is legally authorized to sign the consent form for her child’s surgery, unless her parental rights have been terminated. The sibling, grandparent, provider, and daycare provider lack legal authority unless designated as guardians.
Question 4 of 5
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Correct Answer: A
Rationale: A gastric residual of 300 mL at the end of the shift is unexpected, as residuals exceeding 500 mL every 6 hours may indicate poor gastric emptying or intolerance to feeding, requiring further assessment. Weight gain is expected, a blood glucose level of 110 mg/dL is normal, and one episode of diarrhea is not uncommon with enteral feeding. Abdominal distension would be unexpected but is not listed as a finding here.
Question 5 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Securing tracheostomy ties to allow one finger to fit snugly ensures the tube is stable without being too tight, preventing skin breakdown or dislodgement. Normal saline is not typically used for stoma cleaning (sterile solutions are preferred), soaking the outer cannula in soapy water is not recommended, and cotton tip applicators risk leaving fibers in the cannula. Applying a warm compress is incorrect, as it may promote infection or irritation.