ATI RN
ATI RN Fundamentals 2019 with NGN - Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority?
Correct Answer: B
Rationale: The correct answer is B: Discuss the client's prior coping mechanisms. This is the priority because understanding how the client has coped in the past will help the nurse tailor interventions to provide effective support. By discussing prior coping mechanisms, the nurse can identify strategies that have worked well for the client and build upon them. This can enhance the client's sense of control and emotional well-being during this challenging time.
Choice A (Help the client to find a local support group) may be beneficial, but understanding the client's coping mechanisms should come first.
Choice C (Develop a list of goals with the client) may not be appropriate at this time as the client is dealing with a terminal diagnosis.
Choice D (Teach the client to use progressive relaxation techniques) may be helpful later but is not the priority at this stage.
Question 2 of 5
A nurse is teaching a client about preventing falls at home. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B: I will remove loose rugs from my home. This statement indicates an understanding of fall prevention as loose rugs are a common tripping hazard. Removing them decreases the risk of falls. Keeping floors cluttered (
A) increases the risk of slipping. Walking in socks (
C) can actually decrease traction and increase the risk of slipping. Dimming the lights (
D) can make it harder to see potential hazards and increase the risk of falls.
Therefore, choice B is the best option for fall prevention at home.
Question 3 of 5
A nurse is caring for a client with a central venous catheter. Which of the following actions should the nurse take to prevent infection?
Correct Answer: D
Rationale: The correct answer is D: Cleanse the site with chlorhexidine before dressing changes. This is essential to prevent infection as chlorhexidine is an effective antiseptic that kills bacteria on the skin. First, washing the site with chlorhexidine reduces the risk of introducing bacteria into the catheter during dressing changes. Second, it helps maintain a sterile environment around the catheter insertion site, reducing the chances of infection. Third, it is recommended by evidence-based practice guidelines for central venous catheter care.
Incorrect
Choices:
A: Changing the dressing only when visibly soiled increases the risk of infection as it may not be done frequently enough to prevent bacterial growth.
B: Flushing the catheter with saline every 24 hours is important for maintaining patency but does not directly prevent infection.
C: Using clean gloves for dressing changes is necessary but does not address the need for antiseptic cleansing of the site.
Question 4 of 5
A nurse is assessing a client with suspected hypoglycemia. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Diaphoresis. In hypoglycemia, the body releases epinephrine leading to sweating. Bradycardia (
A) is not typical in hypoglycemia as the body tries to compensate by increasing heart rate. Fever (
C) is not a common symptom of hypoglycemia. Dry skin (
D) is not expected as sweating is common due to sympathetic nervous system activation. In summary, diaphoresis is a classic sign of hypoglycemia due to increased sympathetic response.
Question 5 of 5
A nurse is preparing to administer a vaccine to a client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Verify the vaccine expiration date. This is crucial to ensure the vaccine's effectiveness and safety. Expired vaccines may not provide adequate immunity and could even be harmful. Administering the vaccine in the vastus lateralis (
A) is not necessarily incorrect, but the specific site may vary based on age and vaccine type. Using a 1-inch needle for subcutaneous injections (
B) is incorrect because needle length should be adjusted based on the client's size and the injection site. Injecting the vaccine without aspirating (
D) is unnecessary and not a standard practice for vaccines. In summary, verifying the vaccine expiration date is essential for patient safety and optimal immunization outcomes.