ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
Correct Answer: A, B, D
Rationale:
Correct Answer: A, B, D
Rationale:
A: The physical therapist not ambulating the client is crucial information as it indicates a change in the client's care plan due to the skin barrier issue.
B: The skin barrier's behavior in different positions is relevant to understanding the problem and potential solutions.
D: The wound care nurse's visit is important as it shows ongoing management of the skin barrier issue.
Summary:
C: The client's feelings about physical therapy are not as critical as the actual care provided.
E: The client's food intake is not directly related to the issue with the skin barrier.
F, G: No information is provided about these options in the scenario.
Question 2 of 5
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
Correct Answer: C
Rationale: The correct answer is C. The nurse may assign the task of reapplying a condom catheter for a client who has urinary incontinence to assistive personnel (AP). This task involves a routine procedure that does not require specialized nursing knowledge or assessment skills. It is a straightforward task that can be safely delegated to AP under the supervision of the nurse.
Choices A, B, and D involve more complex care that requires nursing assessment, critical thinking, and specialized skills. Feeding a client with aspiration pneumonia requires monitoring for signs of aspiration, reinforcing teaching about using a quad cane involves patient safety and proper technique, and applying a sterile dressing to a pressure ulcer requires aseptic technique to prevent infection. These tasks should be performed by the nurse to ensure the safety and well-being of the clients.
Question 3 of 5
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. When a nurse suspects aspiration in a client receiving enteral feedings, the highest priority intervention is to immediately stop the feeding to prevent further aspiration and potential respiratory compromise. This action helps to prevent additional complications and allows for further assessment and appropriate interventions. Auscultating breath sounds (choice
A) may confirm the presence of aspiration but stopping the feeding takes precedence. Obtaining a chest x-ray (choice
C) may be necessary later for further evaluation but is not the immediate priority. Initiating oxygen therapy (choice
D) may be needed depending on the client's respiratory status, but stopping the feeding is the first crucial step in managing aspiration.
Question 4 of 5
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Applying the oxygen source loosely if SPO2 decreases ensures adequate oxygenation during the procedure.
B: Using surgical asepsis to remove and clean the inner cannula prevents infection and maintains airway patency.
C: Cleaning the outer surfaces in a circular motion from the stoma site outward prevents contamination of the tracheostomy site.
Summary:
D: Replacing tracheostomy ties is not necessary each time and can cause unnecessary trauma to the patient's skin.
E: Cutting a slit in gauze squares is not a standard practice and may increase the risk of infection.
In summary, choices D and E are incorrect as they are not essential steps in tracheostomy care.
Question 5 of 5
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
Correct Answer: D
Rationale: The correct answer is D: The specimen cannot be contaminated. This is crucial because fecal occult blood testing requires a clean sample to accurately detect blood in the stool. Contamination can lead to false results, affecting the interpretation of the test. Eating more protein (choice
A) is irrelevant to the test procedure. One stool specimen (choice
B) may not be enough for accurate testing. A red color change (choice
C) is not necessarily indicative of a positive test result. By ensuring the specimen is not contaminated, the client can obtain reliable test results.