ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Extract:
A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus.
Question 1 of 5
Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Assessing the client for adverse reactions is the priority because administering an excessive IV fluid bolus (500 mL instead of 250 mL) can lead to immediate complications such as fluid overload, pulmonary edema, or electrolyte imbalances. The nurse must first ensure the client's safety by checking for signs of these adverse effects (e.g., respiratory distress, edema, or changes in mental status). Obtaining vital signs, notifying the provider, and documenting are important but secondary to immediate client assessment. Increasing the IV flow rate is incorrect as it would exacerbate the fluid overload risk.
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 teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Correct Answer: A
Rationale: The client’s belief that education will meet their needs aligns with self-efficacy theory, enhancing motivation to learn. External explanations, family approval, empathy, or fear of needles are less effective motivators.
Question 4 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Covering the percussion area with a towel reduces discomfort during chest percussion. Drainage should be scheduled before meals, clients should exhale slowly during vibration, percussion avoids the lower back, and a heating pad is inappropriate during percussion.
Question 5 of 5
A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
Correct Answer: C
Rationale: The ALT test measures liver enzyme levels, indicating liver function or damage. It does not assess blood clot risk, heart performance, kidney function, or blood sugar levels.