ATI RN
ATI RN Fundamentals Exam 6 Questions
Extract:
Question 1 of 5
A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?
Correct Answer: C
Rationale: Purulent drainage is characterized by the presence of pus indicating infection. Blood-tinged drainage does not necessarily indicate infection. Serous drainage is a clear watery fluid. Blood-tinged drainage has a reddish tinge and is not clear and watery. Sanguineous drainage is characterized by the presence of blood which may be bright red or old and brownish. Blood-tinged drainage falls under the sanguineous category.
Question 2 of 5
A nurse is caring for a client who has been diagnosed with breast cancer. After months of treatment the client refuses to undergo further radiation therapy. Which of the following actions by the nurse is appropriate?
Correct Answer: A
Rationale: Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare. Referring the client to a counselor can be appropriate but the primary response should be to support the client's decision. Encouraging the client not to give up may not be appropriate if the client has made a well-considered decision to refuse further treatment. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.
Question 3 of 5
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Holding the dropper 1/2 inch (1 cm) above the ear canal during administration is the correct action when administering otic medications. This distance helps to ensure that the medication is properly instilled into the ear canal without touching the dropper tip to the skin or ear canal reducing the risk of contamination. Placing a cotton ball into the inner ear canal is not necessary following otic administration. It may cause unnecessary discomfort to the client. Straightening the ear canal by pulling the auricle down and back helps facilitate the administration of otic medications and allows proper placement of the medication into the ear. Applying pressure to the nasolacrimal duct is a technique used for ophthalmic medications not otic medications.
Question 4 of 5
A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?
Correct Answer: B
Rationale: The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.
Question 5 of 5
A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?
Correct Answer: A
Rationale: Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions. Postural drainage is typically done before meals to avoid potential nausea during the procedure. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.