ATI RN Fundamentals 2023 Exam 5 | Nurselytic

Correct Answer: D

Rationale: The correct answer is D: Keep the collection bag below bladder level. This is crucial to prevent backflow of urine into the bladder, reducing the risk of infection. Keeping the collection bag below bladder level ensures a continuous flow of urine out of the bladder and into the bag, minimizing the chances of bacterial migration.

Other choices are incorrect:
A: Using a size 20 French catheter is not directly related to decreasing infection risk.
B: Allowing the drainage bag to fill completely before emptying can increase the risk of infection due to stagnant urine.
C: Disconnecting the drainage tube for catheter irrigation can introduce bacteria into the system.
Overall, maintaining proper positioning of the collection bag is key in preventing catheter-associated urinary tract infections.

Correct Answer: C

Rationale: The correct answer is C: Apply sterile gloves to remove the outer dressing. This is the correct action because it ensures that the nurse maintains a sterile field while obtaining the wound culture specimen. By applying sterile gloves, the nurse minimizes the risk of introducing contaminants to the wound, which could lead to inaccurate culture results or potential infection.



Choices A, B, and D are incorrect because:
A: Rotating the swab over necrotic tissue can introduce contaminants and compromise the accuracy of the culture results.
B: Obtaining the sample from the outer edge of the wound may not provide an accurate representation of the microbial flora present in the wound.
D: Crushing the transport medium after obtaining the specimen can lead to spillage and contamination of the specimen.

By choosing option C, the nurse follows proper sterile technique and ensures the integrity of the wound culture specimen.

Correct Answer: A

Rationale: The correct answer is A. The nurse should see the client with a new onset of dyspnea after a total hip arthroplasty first because it could indicate a pulmonary embolism, a potentially life-threatening complication post-surgery. Dyspnea can be a sign of inadequate oxygenation, which needs immediate assessment and intervention to prevent serious complications. Option B, a urinary tract infection with low-grade fever, can be managed with appropriate antibiotics and does not require immediate attention. Option C, acute abdominal pain of 4 on a scale of 0 to 10, may require evaluation but does not pose an immediate life-threatening risk. Option D, pneumonia with an oxygen saturation of 96%, indicates adequate oxygenation and can be monitored closely without immediate intervention.

Correct Answer: A

Rationale: The correct response is A: 'Why do you feel upset about this?' This is the best choice because it demonstrates active listening and empathy. By asking for the nurse's perspective, the manager shows understanding and opens up a dialogue to address the underlying issues. It acknowledges the nurse's feelings and encourages communication.


Choice B is incorrect as it could come across as dismissive and unhelpful.
Choice C is inappropriate as it jumps to conclusions and could create a negative work environment.
Choice D is also not ideal as it assumes the nurse's feelings without giving them a chance to express themselves. Overall, choice A promotes a constructive and supportive approach to resolving the situation.

Correct Answer: C

Rationale: The correct answer is C because a durable power of attorney becomes enforceable when the client is unable to express their wishes. This is because the appointed individual (the attorney-in-fact) steps in to make decisions on behalf of the client when they are unable to communicate their preferences.
Choice A is incorrect because incapability of self-care doesn't necessarily trigger durable power of attorney.
Choice B is incorrect as being terminally ill doesn't automatically activate durable power of attorney.
Choice D is incorrect as refusing treatment doesn't directly relate to the activation of durable power of attorney.