ATI RN
ATI RN VATI Fundamentals S 2019 Final Questions
Question 1 of 5
A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A. Encouraging fluid intake helps prevent dehydration, which is important when a person has a fever. Fever can increase fluid loss through sweating and evaporation. Adequate fluid intake helps maintain hydration and supports the body's ability to fight infection.
Choice B is incorrect as it suggests a very low fluid intake, which can lead to dehydration.
Choice C is incorrect because maintaining such a low environmental temperature can be uncomfortable and may lead to shivering, which can increase body temperature.
Choice D is incorrect because immersing the client in cold water can cause a rapid drop in body temperature, which may lead to shivering and vasoconstriction, potentially worsening the fever.
Choice E is irrelevant to managing a fever and may not be safe if the client is weak or dizzy.
Question 2 of 5
A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?
Correct Answer: D
Rationale: The correct answer is D: Trace the size of stoma onto the skin barrier. This is crucial as it ensures a proper fit of the ostomy appliance, preventing leaks and skin irritation. By tracing the stoma's size, the nurse can accurately cut the opening in the skin barrier to match the stoma, providing a snug and secure fit. This step is essential for maintaining skin integrity and maximizing comfort for the client.
A: Applying skin sealant on damp skin is not necessary for changing the ostomy appliance and may interfere with proper adhesion.
B: Removing the appliance before emptying the pouch is incorrect as it can lead to unnecessary exposure of the stoma to potential irritants.
C: Ensuring slightly damp skin for better adhesion is not recommended as it may affect the seal and adherence of the ostomy appliance.
Question 3 of 5
A nurse receives a telephone call from a client's family member,who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?
Correct Answer: C
Rationale: The correct answer is C: Refer the family member to the client's provider for the update. This action maintains the client's confidentiality by directing the family member to the appropriate healthcare professional who is authorized to disclose the client's medical information. By doing this, the nurse ensures that sensitive information is shared only with those who have the right to access it, protecting the client's privacy rights.
Explanation for other choices:
A: Requesting additional information about the caller's relationship to the client is unnecessary and could potentially compromise confidentiality.
B: Providing a general update over the telephone can breach the client's confidentiality as the information may not be intended for the family member.
D: Encouraging the family member to contact the client directly is inappropriate as it bypasses the healthcare provider's role in managing and sharing the client's medical information.
Question 4 of 5
A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Wear a surgical mask when within 0.9 m (3 feet) of the client. This is essential to prevent the spread of rubella, which is a highly contagious viral infection transmitted through respiratory droplets. Wearing a surgical mask helps to protect the nurse from inhaling these droplets and reduces the risk of transmission.
A: Instructing the client's loved ones about fresh flowers is not directly related to preventing the spread of rubella.
C: Negative-airflow pressure rooms are typically used for clients with airborne infections like tuberculosis, not for rubella.
D: Instructing the client about visitor restrictions is important, but not the most immediate action to prevent transmission.
In summary, wearing a surgical mask is crucial in this scenario as it directly addresses the prevention of rubella transmission through respiratory droplets.
Question 5 of 5
A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile,saline-soaked dressing which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Correct
Answer: C - Prepare the client for emergency surgery.
Rationale: Evisceration, the protrusion of abdominal organs through the wound, is a surgical emergency that requires immediate intervention. Preparing the client for emergency surgery is crucial to address this life-threatening complication promptly. Prompt surgical repair is necessary to prevent further complications such as infection, organ damage, and potential mortality.
Incorrect
Choices:
A: Positioning the client lying flat may worsen the evisceration and should be avoided.
B: Increasing oral fluid intake is not the priority when facing evisceration; immediate surgical intervention is necessary.
D: Applying pressure to the dressed wound may cause further harm and is not the appropriate action for evisceration.