ATI NUR 5308 RN Fundamental Exam with Rationales
A nurse ispreparing to administer diphenhydramine20 mg orally to a 6-year-old child
who has
... [Show More] difficultyswallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup.
Which of the following images shows the correct # of mLthenurse should administer?
(Round the answer tothenearest whole number.)
Click on thesyringe thathas 8 mLof med.
20 mg x (5mL/12.5mg) = 8 mL
A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80
mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much
cefoxitin should the nurse administer witheach dose?(Round theanswer tothenearest
wholenumber. Usea leading zeroif itapplies.Do not use a trailing zero.)
◗ Soit says eachdosefor thefinal answer,but wearegiven 80 mg/kg/day.
◗ 80 x 20 = 1600 / 4 (doseis given every 6 hours aday) = 400 mg
◗ Rationale: 80 mg x20 kg = 1,600 1,600/4 x day (q6h) = 400 mg
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when
plugging in the IVpump. Which of the following actions should the nursetake first?
Label thepump with adefectiveequipment sticker.
Unplug the pump.
Obtain areplacement pump.
Notified thebiomedical department tofix the pump.
◗ Rationale: Prioritizationquestion.YOU WILL FIRST UNPLUG the IVpump toavoid causing a
fire.
A nurse is caring for a client who has a surgical wound. Which of the following laboratory
values places theclient at risk for poor wound healing?
Serum albumin 3 g/dL
Total lymphocytecount2400 mm3
HCT42%
HGB 16g/dL
◗ Rationale: Albuminin low. Normal rangeis 3.5 to 5.5 g/dL. Low albumin places the
client at risk forpoor wound healing. The other lab values are within normal limits.
A nurse is caring for a client who is scheduled to havehis alanine aminotransferase(ALT)
level checked. Theclientasks the nurse to explain the laboratory test. Which of the following is an
appropriate response by the nurse?
“This test will indicate if you are at risk for developing blood clots
“This test willdetermine if your heart is performing properly”
“This test will provide information about the function of your liver”
◗ Rationale: ALT test measures amount of enzymein blood. ALT mainly found inliver
◗ Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and
BUN measureyour kidney function
“This test isused to check how your kidneys are working”
.
A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally
administers thewhole 10 mg from the single-dosevial. Which of the following actions
should the nursetake first?
Notify theclient’sprovider.
Report theincident tothepharmacy.
Completeanincident report.
Measure the client’s respiratory rate.
◗ Rationale: morphine OD = pulmonary edema fills lungs w/ fluid leading cause of
deathfor OD
◗ Rationale: Morphinecancauserespiratorydepressionif giventoo much. Alsoyou
should ALWAYSASSESS the patient first when a med error is performed to make sure
med error doesn’t put the
client’shealthinrisk.
A nurseis preparing to check a client's blood pressure. Which of the following actions should
the nurse take?
Chapter 27 Vitals signs page 244
Apply the cuff above the client’s antecubital fossa.
Useacuff with a width that is about 60% of theclient's arm circumference. - width of
the cuff should be40 % of arm circumference
How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART
LEVEL
Releasethe pressure on theclient's arm 5 to 6 mm per second. -pressure release
should notbe morethan2to 3 mm hg per second
◗ Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure
no faster than2to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) abovethe
antecubital space with thebrachial
artery inline with the marking onthe cuff. Apply the BP cuff 2.5 cm (1 in) above the
antecubital spacewith the brachial artery in line with the marking on the cuff.
A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following
is an appropriateaction for the nurse to take? Chapter 53 Airway management page 563
Hold thesuction catheter with theclean non-dominanthand.
Apply suctioning for 20 to 30 seconds. - 10 -15 seconds is the maximum.
Placethe catheter inalocation that is clean and dry for later usenew line. - NEVER
EVER REUSETHE SUCTION CATHETER . you throw it away after being used.
Use surgicalasepsis when performing the procedure. - book say medical
asepsis which is maybethe same thing .
◗ Rationale: steriletechnique for trachea
◗ Rationale: ATI FUNDA. PG. 316 Usesurgical asepsis for all types of suctioning. Nolonger
than 10-15seconds to avoid hypoxemia
A nurse is documenting client care. Which of the following abbreviations should the nurse
use?ati book wasnot thorough soi had to go ondifferent sites for charts - not confident with
this, pleasedouble check.
“SS” for sliding scale
“BRP” for bathroom privileges
“OJ” for orange juice- do not
“SQ” for subcutaneous-donot
A nurseis collecting A blood pressure reading from a client who is sitting in a chair
period thenursedetermines that the clients BP is 158/96 mmhg. which of thefollowing
actions should the nursetake?
Ensurethat the widthof the BP cuff is 50% of the client’s upper arm circumference. It
says 40%
Repositiontheclient Supineandrecheckher BP. BP. → ORTHOSTATIC HYPOTENSION
Recheck the clients BP and her otherarm forcomparison.
Request that another nursecheck the the clients BP in 30 minutes. → 15 minutes
A nurse is caring for a client who has left lower atelectasis. in which of the following
positions should thenurseplace the client for postural drainage? Chapter 53 Airway
Management page 562
Supineand low-Fowler's position
Right lateral in Trendelenburg position
Side lying with theright sideof the chest elevated
Prone with pillows under the extremities
A nurseis receiving the prescription for a client who is experiencing dysphagia following
a stroke. Whichof the following prescriptions should the nurse clarify?
Dietitian consult
Speech therapy referral
Oral suction at thebedside
Clear liquids- liquids must be THICK. Clear liquids can cause aspiration
◗ Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed,
mechanically altered,advanced/mechanically soft [Show Less]