ATI RN
ATI Gastrointestinal System
1. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:
- A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion
- B. After insertion into the nostril, instruct the client to extend his neck
- C. Introduce the tube with the client’s head tilted back, then instruct him to keep his head upright for final insertion
- D. Instruct the client to hold his chin down, then back for insertion of the tube
Correct answer: A
Rationale: Instructing the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion helps facilitate the NG tube insertion.
2. In order to establish and maintain successful breastfeeding, which practice should a lactating mother try to follow?
- A. Initiate breastfeeding within 24 hours of birth
- B. Breastfeed on a schedule of every 2 to 3 hours
- C. Give a pacifier to an infant between feedings
- D. Find a breastfeeding support group to troubleshoot problems
Correct answer: D
Rationale: The correct answer is D. Finding a breastfeeding support group is crucial for a lactating mother to establish and maintain successful breastfeeding. This group can offer valuable advice, tips, and encouragement, helping the mother troubleshoot any issues that may arise during breastfeeding. Choices A, B, and C are incorrect because breastfeeding is a natural process that should not be overly scheduled, and giving a pacifier between feedings can interfere with establishing proper breastfeeding techniques.
3. Which of the following vaccines is not done by intramuscular (IM) injection?
- A. Measles vaccine C. Hepa-B vaccine
- B. DPT D. Tetanus toxoids
- C.
- D.
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
4. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
- A. Increase the oxygen flow to 3 L/min.
- B. Assess the client's respiratory status.
- C. Call emergency services for the client.
- D. Have the client cough and expectorate secretions.
Correct answer: Assess the client's respiratory status.
Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.
5. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?
- A. Constant bubbling in the suction-control chamber
- B. Continuous bubbling in the water-seal chamber
- C. Bloody drainage in the collection chamber
- D. Fluid-level fluctuations in the water-seal chamber
Correct answer: Continuous bubbling in the water-seal chamber
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.
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