ATI RN Comprehensive Online Practice A
with NGN GRADED A+ 2024/2025
a charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube, what
actions demonstrate an understanding of the procedure? - ANSWER-- injecting 10-30 mL of air into
the NG tube before checking for residual in order to clear the tube of any feeding, injecting too much
air will lead to abdominal distention and discomfort
- use 20 mL of tap water to flush the NG tube before and after each feeding, DON'T use 0.9% sodium
chloride for irrigation because this can lead to hypernatremia
- keep the head of the bed elevated at 30-45* for 1-2 hours post feeding to decrease the risk of
aspiration
a charge nurse is observing a newly licensed nurse performing a physical assessment on a client,
which of the following actions by the nurse indicate the charge nurse should intervene? - ANSWER-
writing detailed notes during a head to toe assessment, the nurse should only do brief notes during
the assessment in order to avoid delays and write more detailed notes afterwards
a charge nurse is observing a newly licensed nurse performing a physical assessment on a client,
which of the following actions by the nurse indicates the nurse is doing things CORRECTLY - ANSWER-
- while performing a breast examination, the nurse is discussing techniques of breast self-
examination with the client, this gives the nurse the opportunity to demonstrate the correct
technique to the pt
- using a penlight to adequately assess for changes in contour of the body
- using the dorsal surface of the hand to assess skin temperature because it is the more sensitive to
temperature changes
a charge nurse is planning an educational session for staff nurses about working with parents whose
terminally ill children are candidates for donating their organs, which of the following information
should the nurse plan to include? - ANSWER-the family can have the child in an open casket without
fearing that the organ donation might disfigure the child's body
why not the other options?
- choosing to donate organs does NOT delay or affect funeral time or burial expenses
- an autopsy is NOT mandatory prior to organ donation, autopsies are performed following an
unattended death, a suspicious death, or at the request ops the family
,ATI RN Comprehensive Online Practice A
with NGN GRADED A+ 2024/2025
- the nurse should separate discussions about organ donation and the child's impending death, and
SHOULD NOT introduce the option of organ donation to the parents when first discussing the child's
impending death
a charge nurse is planning care for a client who has mechanical restraints in place, which of the
following interventions should the nurse include in the plan? - ANSWER-- remove the restraints when
the patient is calm, in control, and able to follow simple commands
- assess and document the client for physical needs, safety, and comfort every 15-30 min
- check for a new prescription every 4 hours for clients 18 years and older, every 2 hours for pts 9-17
y/o, and every hour for pts under 9 y/o
- have a staff member continuously with or viewing a client either in person or using audiovisual
equipment due to a risk for injury
a charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client
who has anorexia nervosa, which of the following actions should the charge nurse take? - ANSWER-
tell the nurses to stop the discussion because they are violating client confidentially by having the
discussion in a public area
why not the other options?
- don't apologize to the client because the charge nurse should not discuss the nurses action with the
client, the nurse should report the situation to the nursing supervisor to investigate and take further
action
- don't tell the nurses that are being insubordinate because they aren't, insubordination occurs when
an employee disobeys a person in authority, such as a manager or supervisor
- don't document the incident in the client's medical record, instead do an incident report, which is
not included in a client's medical record
a client is exhibiting signs of a cholinesterase inhibitor overdose, when checking the chart the nurse
realizes that the patient has received double the amount of neostigmine than was prescribed, what
medication should the nurse anticipate administering? - ANSWER-atropine
A community health nurse is assisting with the development of a disaster management plan. The
nurse should include which of the following nursing responsibilities in the disaster response stage of
the plan? - ANSWER-performing a rapids needs assessment because this will allow the nurse to
identify the severity of the incident, the health needs of the community, and the priority actions
needed during the response stage
,ATI RN Comprehensive Online Practice A
with NGN GRADED A+ 2024/2025
a home health nurse is assess a 2 week old baby who had a birth weight of 8 lb, what indicates
effective breastfeeding? - ANSWER-- 6-8 wet diapers every day after the 4th day of life
-gaining 0.04-0.06 lbs per day after the 4th-5th day of life, and surpass the initial birth weight within
10-14 days of life
- yellow, soft, and seedy stool at the end of the first week of life, if babies continue to have
meconium in their stools after the first week of life they should be evaluated for ineffective
breastfeeding
a nurse in a ED is admitting a client who has cardiac tamponade, what findings. should the nurse
expect? - ANSWER-- pulsus paradoxus, which is a systolic BP is 10mm or greater during expiration
than inspiration
- jugular vein distention
- bradycardia
- hypotension
- fatigue
- dyspnea
- muffled heart sounds
a nurse is administering cyclophosphamide to a school-aged child who has neuroblastoma, which of
the following actions should the nurse take when administering this medication? - ANSWER--
maintain hydration with liberal fluid intake in order to prevent hemorrhagic cystitis, which is an
adverse effect of this medication
- administer an antiemetic 30 min before administration to decrease GI effects
why not the other options?
- you DON'T need to monitor for tumor lysis syndrome because this is can occur in patients with
acute lymphoblastic leukemia, not neuroblastoma
- you don't need to monitor blood glucose levels because cyclophosphamide does not affect blood
sugar
A nurse is assessing a client during the immediate postpartum period. Which of the following
findings requires immediate intervention by the nurse? - ANSWER-boggy uterus because this can
indicate uterine hemorrhage and this is URGENT
, ATI RN Comprehensive Online Practice A
with NGN GRADED A+ 2024/2025
why do the other findings not require immediate intervention by the nurse?
- intermittent cramping, moderate lochia rubra, and perineal edema are all NONURGENT and are
expected findings
- excessive lochia rubra and large clots should be reported to the provider
- intermittent cramping/afterpainscan be eased by heat and lying prone
- perineal edema occurs due to the excessive amount of pressure experienced during vaginal birth,
the nurse can offer ice or sitz baths
A nurse is assessing a client who has antisocial personality disorder. Which of the following
manifestations should the nurse expect? - ANSWER-lack of remorse
A nurse is assessing a client who has been taking lithium carbonate for the past month to treat
bipolar disorder. Which of the following assessment findings should the nurse identify as the
priority? - ANSWER-confusion because this is an early indicator of lithium toxicity, the nurse should
monitor for other indications of lithium toxicity such as: coarse hand tremors, incoordination, ECG
changes, sedation
what are signs that are EXPECTED adverse effects?
lethargy, polyuria, fine hand tremors
A nurse is assessing a client who has bipolar disorder. Which of the following manifestations should
the nurse expect? - ANSWER-extreme mood swings
A nurse is assessing a client who has borderling personality disorder. Which of the following
manifestations should the nurse expect? - ANSWER-self-mutilating behaviors
A nurse is assessing a client who has narcissistic personality disorder. Which of the following
manifestations should the nurse expect? - ANSWER-sensitivity to rejection
