ATI RN FUNDAMENTALS ALL QUESTIONS
AND CORRECT ANSWERS ALREADY A+.
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 f - CorreCt Answers -A
this action clears the excess formula preventing any clumps/clogging
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 - CorreCt Answers -B
the greatest risk is aspiration so verifying the placement of the tube is most
important
,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?
A. Auscultate breath sounds
B. Stop the feeding
C. Obtain a chest xray
D. Initiate oxygen therapy - CorreCt Answers -B. Stop the feeding
A nurse is caring for a client in a long-term care facility who is receiving
enteral feedings via NG tube. Which of the following is an appropriate
nursing action prior to administering the tube feeding? Select all.
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temp.
E. Discard any residual gastric contents. - CorreCt Answers -A, B, C
D-the formula should be room temp not body
E-unless the volume of the contents is more than 250 mL, the nurse should
return the residual content to the client's stomach
A nurse is preparing to insert an NG tube for a client who requires gastric
decompression. Which of the following actions should the nurse perform
prior to beginning the procedure? Select all.
,A. Review a signal the client can use if feeling any distress
B. Lay a towel across the client's chest
C. Administer oral pain meds
D. Obtain a Dobhoff tube for insertion
E. Have a petroleum-based lubricant available - CorreCt Answers -A, B
An adolescent who has diabetes mellitus is 2 days postop following an
appendectomy. The client is tolerating a regular diet. He has ambulated
successfully around the unit w/assistance. He requests pain meds Q 6-8 hr
while reporting pain at a 2 on a scale of 1-10 after receiving the med. His
incision is approximated & free of redness, w/scant serous drainage on the
dressing. Which of the following risk factors for poor wound healing does
this client have? Select all.
A. Extremes in age
B. Impai - CorreCt Answers -B, C
A nurse is assessing a client who is 5 days post op following abd. surgery.
The surgeon suspects an incisional wound infection & has prescribed
antibiotic therapy for the nurse to initiate after collecting wound & blood
specimens for culture & sensitivity. Which of the following assessment
findings should the nurse expect? Select all.
A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
, E. Decrease in thirst - CorreCt Answers -A, B, C
A nursing instructor is reviewing the wound healing process w/a group of
nursing students. They should be able to identify which of the following
alterations as a wound or injury that heals by secondary intention? Select
all.
A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed w/adhesive
E. Open burn area - CorreCt Answers -A, E
B and D are healed w/primary intention
C is not a skin wound unless bone has pierced the skin
A client who had abd. surgery 24 hr ago reports a pulling sensation & pain
in his surgical incision. The nurse checks the client's surgical wound & finds
the wound separated w/viscera protruding. Which of the following
interventions is appropriate? Select all.
A. Cover the area w/saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abd.
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the client supine w/his hips & knees bent
E. Offer - CorreCt Answers -A, D
AND CORRECT ANSWERS ALREADY A+.
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 f - CorreCt Answers -A
this action clears the excess formula preventing any clumps/clogging
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 - CorreCt Answers -B
the greatest risk is aspiration so verifying the placement of the tube is most
important
,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?
A. Auscultate breath sounds
B. Stop the feeding
C. Obtain a chest xray
D. Initiate oxygen therapy - CorreCt Answers -B. Stop the feeding
A nurse is caring for a client in a long-term care facility who is receiving
enteral feedings via NG tube. Which of the following is an appropriate
nursing action prior to administering the tube feeding? Select all.
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temp.
E. Discard any residual gastric contents. - CorreCt Answers -A, B, C
D-the formula should be room temp not body
E-unless the volume of the contents is more than 250 mL, the nurse should
return the residual content to the client's stomach
A nurse is preparing to insert an NG tube for a client who requires gastric
decompression. Which of the following actions should the nurse perform
prior to beginning the procedure? Select all.
,A. Review a signal the client can use if feeling any distress
B. Lay a towel across the client's chest
C. Administer oral pain meds
D. Obtain a Dobhoff tube for insertion
E. Have a petroleum-based lubricant available - CorreCt Answers -A, B
An adolescent who has diabetes mellitus is 2 days postop following an
appendectomy. The client is tolerating a regular diet. He has ambulated
successfully around the unit w/assistance. He requests pain meds Q 6-8 hr
while reporting pain at a 2 on a scale of 1-10 after receiving the med. His
incision is approximated & free of redness, w/scant serous drainage on the
dressing. Which of the following risk factors for poor wound healing does
this client have? Select all.
A. Extremes in age
B. Impai - CorreCt Answers -B, C
A nurse is assessing a client who is 5 days post op following abd. surgery.
The surgeon suspects an incisional wound infection & has prescribed
antibiotic therapy for the nurse to initiate after collecting wound & blood
specimens for culture & sensitivity. Which of the following assessment
findings should the nurse expect? Select all.
A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
, E. Decrease in thirst - CorreCt Answers -A, B, C
A nursing instructor is reviewing the wound healing process w/a group of
nursing students. They should be able to identify which of the following
alterations as a wound or injury that heals by secondary intention? Select
all.
A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed w/adhesive
E. Open burn area - CorreCt Answers -A, E
B and D are healed w/primary intention
C is not a skin wound unless bone has pierced the skin
A client who had abd. surgery 24 hr ago reports a pulling sensation & pain
in his surgical incision. The nurse checks the client's surgical wound & finds
the wound separated w/viscera protruding. Which of the following
interventions is appropriate? Select all.
A. Cover the area w/saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abd.
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the client supine w/his hips & knees bent
E. Offer - CorreCt Answers -A, D
