NR 324: EXAM REVIEW ATI RN FUNDAMENTALS Q AND A
1. 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
2. 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
3. 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.
,4. 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
5. 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. Impaired circulation
C. Impaired/suppressed immune system
D. Malnutrition
E. Poor wound care
6. 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
7. 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
8. 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
1. 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
2. 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
3. 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.
,4. 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
5. 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. Impaired circulation
C. Impaired/suppressed immune system
D. Malnutrition
E. Poor wound care
6. 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
7. 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
8. 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
