ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Extract:
Question 1 of 5
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
Correct Answer: C
Rationale: Emptying the reservoir is the appropriate action because a Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied. The bulb should be emptied before it is more than half full to prevent complications such as hematoma formation, infection, drain occlusion, and delayed wound healing. Leaving it until the end of the shift risks these complications. Removing the drain without a surgeon's order could disrupt healing, and notifying the surgeon is not necessary unless there are signs of excessive bleeding (e.g., bright red blood, clots, or drainage >100 ml in 24 hours). Applying pressure to the drain site is incorrect as it does not address the reservoir’s function and could disrupt the drain’s placement.
Question 2 of 5
A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?
Correct Answer: B
Rationale: An occupational therapist specializes in assisting with ADLs, helping the stroke client regain independence in daily tasks. Physical therapists focus on mobility, speech-language pathologists address communication/swallowing, dieticians manage nutrition, and social workers handle psychosocial needs.
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 3 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 4 of 5
A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number.)
Correct Answer: A
Rationale: Convert 220 lb to kg: 220 ÷ 2.2 = 100 kg. Calculate dose: 100 kg × 2 mg/kg = 200 mg. Thus, the nurse should administer 200 mg of gentamicin. 300 mg is incorrect, as it assumes a 150 kg weight.
Question 5 of 5
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?
Correct Answer: D
Rationale: In the contemplation stage, the client is considering change but not yet ready to act. Presenting information about the benefits of quitting smoking helps motivate the client by highlighting positive outcomes, such as reduced heart attack risk and improved lung function. Developing a plan, recommending changes, or setting goals are more appropriate for later stages (preparation or action). Providing nicotine replacement therapy is premature without a plan.