ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Question 1 of 5
A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?
Correct Answer: A
Rationale:
Correct
Answer: A. Rub soap on hands for 20 seconds.
Rationale: Rubbing soap on hands for 20 seconds allows for proper coverage of all hand surfaces, ensuring effective removal of dirt and germs. The friction created during this process helps dislodge pathogens. The recommended duration of 20 seconds is based on research supporting its effectiveness in reducing microbial load. This thorough technique is essential for proper hand hygiene.
Summary of Incorrect
Choices:
B: Allowing hands and arms to dry is important after washing hands, but it is not the main action for hand hygiene effectiveness.
C: Holding the hands higher than the elbows does not contribute significantly to hand hygiene efficacy.
D: Adjusting the water temperature to feel hot may not be necessary and can lead to skin irritation. The focus should be on using soap and rubbing hands for the recommended duration.
Question 2 of 5
A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. In opioid overdose, respiratory depression can occur, leading to inadequate ventilation, causing retention of carbon dioxide and respiratory acidosis. This results in an increase in carbon dioxide levels in the blood, leading to acidosis. Metabolic acidosis (choice
A) is not directly related to opioid overdose. Respiratory alkalosis (choice
C) is unlikely as alkalosis results from hyperventilation, which is not typically seen in opioid overdose. Metabolic alkalosis (choice
D) is not related to respiratory depression caused by opioids.
Question 3 of 5
A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?
Correct Answer: B
Rationale: The correct answer is B: Daily weight measurement. Daily weight monitoring is a reliable measure of fluid retention in clients with CHF because sudden weight gain can indicate fluid accumulation due to the heart's inability to pump effectively. This method helps track changes in fluid status, guiding treatment adjustments. Cardiac monitoring (
A) primarily assesses heart rhythm and function, not fluid retention. Blood pressure monitoring (
C) is important but may not directly reflect fluid status. Urine output measurement (
D) is useful for assessing kidney function but may not provide a comprehensive picture of fluid retention.
Question 4 of 5
A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. How should the nurse explain to the client how this method of oxygen delivery performs?
Correct Answer: D
Rationale: The correct answer is D: Delivers a constant flow of a specific concentration of oxygen. Nasal cannula delivers oxygen at a constant flow rate, ensuring a consistent concentration of oxygen for the client. This method allows for precise control of oxygen delivery based on the client's needs.
Choice A is incorrect because a nasal cannula can provide varying concentrations based on the flow rate.
Choice B is incorrect as it doesn't specify the concentration of oxygen being delivered.
Choice C is incorrect as nasal cannula typically delivers a lower concentration of oxygen compared to other methods like a mask.
Question 5 of 5
A nurse accidentally sticks her hand with a needle after administering an intramuscular (IM) injection to a client. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A. Washing the area of the puncture thoroughly with soap and water is the first priority to prevent infection. This action helps to clean the wound and reduce the risk of contamination. It is crucial to remove any potential pathogens that may have entered through the puncture site. Notifying employee health services (
B) and reporting the incident to the charge nurse (
D) are important steps to take after cleaning the wound, but they should follow the immediate cleaning of the site. Completing an incident report (
C) is also necessary but is a documentation step that can be done after addressing the immediate risk of infection.