ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?
Correct Answer: A
Rationale: The correct answer is A: Surgical mask. The nurse should use a surgical mask when caring for a client with bacterial meningitis to prevent the spread of infectious droplets. A surgical mask is sufficient for this infection, as it primarily spreads through respiratory droplets. Using an N95 respirator, sterile gloves, or a gown and face shield would be unnecessary and excessive for this particular situation, as they are typically reserved for airborne precautions or when there is a high risk of contact with bodily fluids. Thus, the use of a surgical mask is the most appropriate and effective choice in this scenario.
Question 2 of 5
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (
B) and neck vein distention (
C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (
D) suggests fluid retention, not deficit.
Question 3 of 5
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (
B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (
C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (
D) is not the first priority in this situation; preventing air embolism is critical.
Question 4 of 5
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Place monitoring cords and tubes in a stockinette. This is important for the client with a latex allergy because stockinettes provide a barrier between the latex-containing materials and the client's skin, reducing the risk of allergic reactions. Using powder-free latex gloves (choice
A) is a good practice, but it is not directly addressing the risk of exposure to latex for the client. Avoiding iodine-based antiseptics (choice
C) is not necessary unless the client has a specific allergy to iodine. Administering prophylactic antihistamines (choice
D) is not a standard practice for latex allergies and may not prevent an allergic reaction.
Question 5 of 5
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: The stool will have a high volume of liquid. Following a colectomy with an ileostomy, the client will have fecal output from the small intestine, resulting in a high volume of liquid stool. This is because the large intestine, responsible for absorbing water and forming solid stool, is bypassed with an ileostomy.
Choice A is incorrect because the stool will not be firm and well-formed.
Choice C is incorrect because the stool will not be similar to normal bowel movements due to the absence of the large intestine.
Choice D is incorrect as the stool will not be hard and difficult to pass.