ATI RN
ATI Fundamentals Proctored Exam 2023
1. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?
- A. Administer the feeding over 30 minutes
- B. Place the child in a supine position after the feeding
- C. Change the feeding bag and tubing every 3 days
- D. Warm the formula in a warm water bath before administration
Correct answer: B
Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.
2. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?
- A. Store the glasses in a labeled case.
- B. Clean the glasses with hot water
- C. Clean the glasses with a paper towel.
- D. Store the glasses on the bedside table.
Correct answer: A
Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.
3. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?
- A. Arrange for an ethics committee meeting to address the family's concerns.
- B. Support the family's decision and initiate life-sustaining measures.
- C. Complete an incident report.
- D. Encourage the family to contact an attorney.
Correct answer: A
Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.
4. A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?
- A. Your baby needs an IV because she is not producing any tears
- B. Your baby needs an IV because her fontanels are bulging
- C. Your baby needs an IV because she is breathing slower than normal
- D. Your baby needs an IV because her heart rate is decreasing
Correct answer: A
Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.
5. A client is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
- A. Cleanse equipment before removal from the client's room.
- B. Limit the client's visitors to 30 minutes per day.
- C. Discard the client's linens in a double bag.
- D. Discard the radioactive source in a biohazard bag
Correct answer: D
Rationale: When caring for a client receiving brachytherapy, it is crucial to handle radioactive sources appropriately. Discarding the radioactive source in a biohazard bag is essential to prevent exposure to radiation. Cleaning equipment before removal, limiting client's visitors, or discarding linens in a double bag are not specific to the management of radioactive sources in brachytherapy.
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