ATI RN
RN ATI FUNDAMENTALS 2024 EXAM Questions
Extract:
Nurses' Notes: Day 1
Lactated Ringer'sat 100 mbhr infusing into a 20-guage IV catheter in left hand. IV ressing dry and Intact. IV site without redness or swelling. IV fluld infusing vl [ Place a pressure chessing over the IV site.
(03 Apply heat to the clients left hand.
Day2 [ start.a newIV inthe clentβs eft hand. IV site edematous. Skin surrounding catheter site taut blanched, and cool to touch. IV fluid not nfusing.
Question 1 of 5
A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
Correct Answer: A, B, C
Rationale:
Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The client's IV site is showing signs of infiltration (edematous, cool skin, IV fluid not infusing), which can lead to tissue damage. Stopping the infusion is crucial to prevent further harm.
B: Place a pressure dressing over the IV site - A pressure dressing can help reduce swelling and prevent further infiltration of fluid into the surrounding tissues.
C: Apply heat to the client's left hand - Applying heat can help dilate blood vessels and improve circulation, which may help reduce the effects of infiltration and promote tissue healing.
Summary of Incorrect
Choices:
D: Starting a new IV in a different site is not necessary at this moment. The priority is to address the infiltration issue with the current IV.
E, F, G: No additional choices were provided, but they would likely be incorrect as they do not address the immediate concern of the IV site infiltration.
Extract:
Question 2 of 5
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
Correct Answer: A, B, C, E
Rationale: The correct choices are A, B, C, and E.
A) Wearing an N95 mask is essential for respiratory protection.
B) Placing a container for soiled linens in the room prevents contamination.
C) Isolating the client in a negative airflow room helps prevent the spread of airborne pathogens. E) Wearing a sterile water-resistant gown within 3 feet of the client reduces the risk of contact transmission.
D) Removing the mask after exiting the room increases the chance of self-contamination. Thus, D is incorrect. Option F and G are not provided in the question.
Question 3 of 5
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is important because opioids are controlled substances and must be securely stored to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that only authorized personnel have access to it, maintaining safety and compliance.
Other choices are incorrect:
A: Asking another nurse to observe the medication wastage is not necessary in this situation as the issue is about proper storage, not administration.
B: Notifying the pharmacy when wasting the medication is not relevant here as the focus should be on proper disposal and storage.
D: Disposing of the vial with the remaining medication in a sharps container is incorrect as controlled substances should be handled and stored appropriately, not simply disposed of in a sharps container.
Question 4 of 5
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique when performing tracheostomy care at home. This is vital to prevent infections and complications. Sterile technique involves maintaining cleanliness and minimizing the risk of introducing pathogens.
Choices A, B, and D are incorrect. A: Removing the outer cannula carelessly can cause injury or displacement. B: Using tracheostomy covers outdoors is important for filtration but not the primary aspect of care. D: Cleaning mist with hydrogen peroxide can be harmful to the skin and mucous membranes.
Question 5 of 5
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 107
Rationale:
To calculate the infusion rate, divide the total volume to be infused (750mL) by the total time in hours (7 hours). 750mL / 7 hours = 107 mL/hr. This is the correct answer as it determines the rate at which the solution should be administered to ensure the correct dosage is delivered over the specified time. Other choices are incorrect as they do not result from the correct calculation method, which is essential in determining the appropriate infusion rate for the patient.