ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?
Correct Answer: A
Rationale: Tuberculosis requires airborne precautions due to its transmission via tiny airborne droplets. Pneumonia and strep throat require droplet precautions, while shigella requires contact precautions.
Question 2 of 5
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
Correct Answer: C
Rationale: Changing the dressing four times per day is excessive and not typically recommended. Most guidelines suggest changing the dressing once a day or as needed if it becomes soiled or wet. Over-frequent dressing changes can disrupt the healing process and increase the risk of infection. Applying tincture of benzoin prior to removing the dressing is not a standard practice for wound care. Tincture of benzoin is usually used to increase the adhesion of bandages or tapes, not for removing dressings. Using it inappropriately could cause skin irritation or damage. Cleaning from the incision to the surrounding skin is the correct method. This technique helps prevent the spread of bacteria from the surrounding skin into the incision site, reducing the risk of infection. Always use a sterile solution and clean gauze for this process. Using sterile gloves when removing the old dressing is important to maintain a sterile environment and prevent infection. However, this is a general practice and not specific to the wound care instructions provided in the question.
Question 3 of 5
A nurse is caring for a client who has an NG tube set to low-intermittent suction for gastric decompression. The nurse observes that the NG tube is not draining. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Lowering the bed to 15 degrees may assist drainage but is less effective than clearing a potential blockage. Injecting 10 mL of air into the vent lumen is a standard technique to dislodge obstructions, restoring drainage. High suction risks gastric mucosa damage, and connecting the air vent to suction disrupts its purpose of preventing adherence to the stomach lining.
Question 4 of 5
A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Leaving a transfer belt in place until the client returns from radiology is not recommended. The transfer belt is used to assist in moving the client safely, but it should be removed once the client is securely seated in the wheelchair to prevent discomfort or potential injury. Positioning the client so their weight is shifted forward is not a standard practice for transferring a client to a wheelchair. Proper positioning involves ensuring the client is seated comfortably and securely, with their weight evenly distributed to prevent falls or injuries. Lowering the footplates before transferring the client from the bed is incorrect. The footplates should be raised to allow the client to safely transfer from the bed to the wheelchair without tripping or getting their feet caught. Backing the wheelchair into the elevator is the correct action. This ensures that the client enters the elevator facing forward, which is safer and more comfortable for the client. It also allows the nurse to maintain better control of the wheelchair during the transition.
Question 5 of 5
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: B,C,E
Rationale: A negative Chvostek's sign is not expected in a client with hypocalcemia. The Chvostek's sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek's sign indicates neuromuscular irritability due to low calcium levels.
Therefore, a negative Chvostek's sign would not be consistent with hypocalcemia. A positive Trousseau's sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau's sign, indicating neuromuscular irritability due to low calcium levels. Muscle cramps are a common symptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort. Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention. Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.