ATI RN Fundamentals Proctored Exam Questions with Verified Answers|100% Correct|2023/2024 New Update
1. A nurse is preparing to administer digoxin
... [Show More] (Lanoxin) to a client who states, "I don't want to take that med. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation?
A. "Your physician prescribed it for you, so you really should take it."
B. "Well, let's just get it over w/quickly then."
C. "Okay, I'll just give you your other meds."
D. "Tell me your concerns w/taking this med."
Answer: D.
2. A nurse is assessing a client who has an acute resp. infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Pallor
Answer: A, B, E
C and D are late manifestations of hypoxemia.
3. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
A. Increase the oxygen flow
B. Assist the client to Fowler's position
C. Promote removal of pulmonary secretions
D. Obtain a specimen for arterial blood gases
Answer: B
Fowler's facilitates better breathing
4. A nurse is preparing to preform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
A. Apply suction while withdrawing the catheter
B. Perform suctioning on a routine basis, Q2-3 hours
C. Maintain medical asepsis during suctioning
D. Use a new catheter for each suctioning attempt
E. Limit suctioning to 2-3 attempts
Answer: A, D, E
B-Suctioning is not w/out risk so it should be done as needed, not routinely.
C-endotracheal suctioning requires surgical asepsis
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.
A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
B. Use surgical asepsis to remove & clean the inner cannula
C. Clean the outer surfaces in a circular motion from the stoma site onward
D. Replace the tracheostomy ties w/new ties
E. Cut a slit in gauze squares to place beneath the tube holder.
Answer: A, B, C
D-only replace ties if soiled or wet
E-use a commercially prepared gauze w/slit not one nurse makes
6. A provider is discharging a client with a prescription from home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.
A. Apply petroleum jelly around the inside of the nares
B. Remove the nasal cannula during mealtimes
C. Check the position of the cannula often
D. Report any nasal stuffiness, nausea, or fatigue
E. Post "no smoking" signs in a prominent location
Answer: C, D, E
7. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse?
A. "Water helps clear the tube so it doesn't get clogged."
B. "Flushing helps make sure the tube stays in place."
C. "This will help you get enough fluids."
D. "Adding water makes the formula less concentrated."
Answer: A
this action clears the excess formula preventing any clumps/clogging
8. A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure?
A. Check how long the feeding container has been opened
B. Verify the placement of the NG tube
C. Confirm that the client doesn't have diarrhea
D. Make sure the client is alert & oriented
Answer: B
the greatest risk is aspiration so verifying the placement of the tube is most important
9. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? [Show Less]