ATI RN
ATI N103N103 Fundamentals Final Exam Questions
Question 1 of 5
A client asks the nurse about a prescription for the antihistamine, diphenhydramine (Benadryl). The nurse should teach the client that this medication is contraindicated in clients who have a history of which condition?
Correct Answer: C
Rationale: The correct answer is C: Glaucoma. Diphenhydramine is contraindicated in clients with glaucoma because it can increase intraocular pressure, potentially exacerbating the condition. This can lead to vision problems and worsen the symptoms of glaucoma. Asthma (choice
A), hypertension (choice
B), and depression (choice
D) are not contraindications for diphenhydramine use. Asthma and hypertension may actually benefit from the antihistamine effects of diphenhydramine. Depression is not directly affected by diphenhydramine use.
Question 2 of 5
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an abdominal wound. The nurse should understand that the JP drain was placed for which purpose?
Correct Answer: D
Rationale: The correct answer is D:
To prevent fluid from accumulating in the wound. A Jackson-Pratt drain is a closed suction system used to remove excess fluid from a surgical site to prevent seroma or hematoma formation. By creating negative pressure, the drain helps to promote wound healing and reduce the risk of infection.
Choice A is incorrect because a JP drain is not used for medication administration.
Choice B is incorrect as wound dressings are still needed despite the drain.
Choice C is incorrect as the primary purpose of a JP drain is not to limit bleeding but to remove fluid.
Question 3 of 5
A nurse is assessing a client's wound and notes there is slough present. What would be an appropriate intervention for this wound?
Correct Answer: C
Rationale: The correct answer is C: Debride. Slough is dead tissue that needs to be removed to promote wound healing. Debridement is the process of removing necrotic tissue, which helps prevent infection and supports the growth of healthy tissue. Covering the wound (choice
A) without addressing the slough may lead to further complications. Simply cleaning the wound (choice
B) may not effectively remove the slough. Leaving the wound alone (choice
D) can hinder healing progress.
Therefore, debriding the wound is the most appropriate intervention to facilitate proper wound healing.
Question 4 of 5
A nurse is giving preoperative instructions to a patient scheduled for surgery. The patient tells the nurse, 'I will prepare my advance directives before I come to the hospital.' Which statement shows the client understands advance directives?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific preference regarding medical treatment. Choosing not to be kept on a breathing machine is a clear directive that guides healthcare decisions. Option A is incorrect because the patient's regular doctor does not need to approve advance directives for them to be valid. Option B is incorrect as advance directives are not a requirement for surgery. Option D is incorrect because the patient should specify their own preferences, not rely on someone else to make decisions for them.
Question 5 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.