ATI RN Fundamental Proctored Exam With NGN Graded -Nurselytic

Correct Answer: A, C, E

Rationale:
Correct
Answer: A, C, E


Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.

Incorrect

Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.

Correct Answer: A

Rationale:
Correct
Answer: A: Don't measure the client's temperature rectally.


Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa.
Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.

Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.

Correct Answer: A, B, C

Rationale: The correct guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate.

Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.

Correct Answer: B

Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice
A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice
C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice
D) is not as proactive as addressing the potential pain issue immediately.

Correct Answer: D

Rationale: The correct answer is D because a contaminated specimen can lead to false results. The client should be instructed to avoid contaminating the specimen with urine, water, or toilet bowl cleaners.
Choice A is incorrect because protein intake does not affect the test.
Choice B is incorrect as multiple stool specimens are usually required.
Choice C is incorrect as a blue color change indicates a positive test, not red.