ATI RN
Fundamental Of Nursing Nclex Practice Questions Questions
Question 1 of 5
What is the most important legal responsibility for the healthcare team after a patient's death in a hospital?
Correct Answer: D
Rationale: After a patient's death in a hospital, the most crucial legal responsibility for the healthcare team is ensuring that the attending physician issues the death certificate. The death certificate is a vital legal document that confirms the cause of death and is required for legal and administrative purposes, including the completion of the patient's medical records and facilitating the family's ability to proceed with funeral arrangements and insurance claims. While other actions such as obtaining consent for an autopsy, notifying the coroner or medical examiner, and labeling the body appropriately are important, ensuring the timely and accurate issuance of the death certificate takes precedence in this scenario.
Question 2 of 5
During a seizure, what is the primary intervention?
Correct Answer: A
Rationale: The primary intervention during a seizure is to protect the patient from injury. This includes moving nearby objects that may harm the patient, cushioning the head, and ensuring a safe environment until the seizure subsides. Inserting an airway is not typically done during a seizure unless the patient's airway is compromised, while elevating the head of the bed is not the priority during an active seizure. Withdrawing all pain medications is not necessary unless there are specific contraindications related to the seizure event.
Question 3 of 5
According to the principles of standard precautions, when should gloves be worn by healthcare providers?
Correct Answer: D
Rationale: The correct answer is D (Providing oral hygiene) because standard precautions mandate glove use during procedures involving contact with mucous membranes, non-intact skin, or potential exposure to bodily fluids. Oral hygiene involves contact with saliva and oral mucosa, both of which are potential sources of pathogens like herpes simplex virus, cytomegalovirus, or blood from gingival bleeding. Gloves act as a barrier to prevent cross-contamination between the healthcare provider and the patient, reducing transmission risks. Additionally, oral care often requires handling used toothbrushes or floss, which may harbor microorganisms. Choice A (Providing a back massage) is incorrect because it typically involves intact skin contact without exposure to bodily fluids or mucous membranes. Standard precautions do not require gloves for non-invasive touch unless the patient has open wounds or lesions on their back. While hand hygiene is essential, gloves are unnecessary unless there's a specific risk of fluid exposure, which is unlikely during routine massage. Choice B (Feeding a client) is incorrect because it does not ordinarily involve contact with bodily fluids or mucous membranes. Unless the patient requires assistance with oral intake due to dysphagia (which might involve saliva or food residue), gloves are not required. In fact, glove use during feeding may compromise patient dignity and tactile sensitivity needed for safe assistance. Handwashing before and after the task suffices for infection control. Choice C (Providing hair care) is incorrect because routine hair washing or brushing does not involve exposure to bodily fluids or mucous membranes. Gloves might only be necessary if the patient has scalp lesions or drainage, which would fall under transmission-based precautions rather than standard precautions. For most hair care activities, hand hygiene is adequate to maintain infection control standards. The rationale for glove use under standard precautions hinges on risk assessment: procedures with predictable exposure to potentially infectious materials require gloves, while those without such exposure do not. This distinction ensures both patient and provider safety while avoiding unnecessary glove use, which can contribute to resource waste and latex sensitivity development. Oral hygiene uniquely meets the criteria for glove use due to its inherent contact with moist body surfaces and potential for fluid exposure.
Question 4 of 5
The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature?
Correct Answer: A
Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely.
Question 5 of 5
A nurse obtained a client's pulse and found the rate to be above normal. The nurse documents this finding as:
Correct Answer: D
Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.