ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
Correct Answer: B
Rationale: Using extension cords to prevent overloading circuits is not a recommended safety practice. Extension cords can pose tripping hazards and may not be designed to handle the electrical load of multiple devices, which can lead to overheating and potential fire risks. Obtaining a raised toilet seat for the bathroom is a practical safety measure for older adults. It helps reduce the risk of falls by making it easier for individuals with limited mobility to sit down and stand up from the toilet. This modification can significantly enhance bathroom safety. Covering slippery stairs with an area rug is not advisable. Area rugs can slip and create additional hazards. Instead, using non-slip treads or securing the rug with non-slip backing is a safer alternative. Securing loose wires under carpeting is not recommended. This practice can create a fire hazard and make it difficult to access the wires if needed. It's better to use cable management solutions that keep wires organized and out of the way without hiding them under carpeting.
Question 2 of 5
A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Using sterile gloves to obtain the sputum specimen is important for maintaining sterility and preventing contamination. However, it is not the first priority action. The timing of the collection is more critical to ensure the accuracy and quality of the specimen. Obtaining the sputum specimen after the client uses mouthwash is incorrect. Mouthwash can kill or alter the microorganisms present in the sputum, leading to inaccurate test results. The client should rinse their mouth with water instead to reduce contamination from oral secretions. Collecting the sputum specimen in the morning is the most appropriate action. Sputum accumulates overnight, making it easier to collect a sufficient sample in the morning. This timing also ensures that the specimen is more concentrated and representative of the lower respiratory tract. Placing the sputum specimen in a clean container is necessary, but it is not the first action to take. The container should be sterile to prevent contamination and ensure the accuracy of the test results. However, the timing of the collection is more critical to obtaining a quality specimen.
Question 3 of 5
A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: A,B,C,D,E
Rationale: Inspection (
A) comes first to observe visually, followed by auscultation (
B) to avoid altering bowel sounds, then percussion (
C) to assess underlying structures, light palpation (
D) to check tenderness, and deep palpation (E) to assess deeper structures like the aorta.
Question 4 of 5
A nurse is planning care for a client who has a seizure disorder. Which of the following actions should the nurse include in the client's plan of care?
Correct Answer: C
Rationale: Having a padded tongue blade available at the client's bedside is not recommended for seizure management. Inserting any object into a patient's mouth during a seizure can cause injury to the teeth, gums, or jaw. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus should be on ensuring the patient's safety by turning them on their side to maintain an open airway and prevent aspiration. Keeping the four side rails down when the client is in bed is not advisable for a client with a seizure disorder.
To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls. Keeping suction equipment available in the client's room is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client's airway, reducing the risk of aspiration and ensuring the client can breathe properly. Having wire cutters available at the client's bedside is not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders.
Question 5 of 5
A charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Correct Answer: B
Rationale: Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process. Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client's pain during the procedure, ensuring comfort and compliance. Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique. Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.