ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has tuberculosis. The nurse should anticipate which isolation precautions for the client?
Correct Answer: A
Rationale: Airborne precautions are necessary for clients with tuberculosis (T
B) because TB is an airborne disease. It is transmitted through tiny droplets released into the air when an infected person coughs, sneezes, or talks. These precautions include placing the client in a negative pressure room, using N95 respirators for healthcare workers, and ensuring the client wears a surgical mask when outside their room. These measures help prevent the spread of TB to others. Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. These precautions are not appropriate for a client with TB, as the primary concern is preventing the spread of TB from the infected client to others, not protecting the client from external infections. Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment, such as MRSA or C. difficile. TB is not spread through contact but through airborne particles, so contact precautions are not sufficient for preventing the transmission of TB. Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. While TB is a respiratory disease, it is spread through much smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions necessary instead of droplet precautions.
Question 2 of 5
A nurse is obtaining a specimen for a wound culture from a client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Rotating the swab over necrotic tissue is not recommended because necrotic tissue does not provide an accurate representation of the microorganisms present in the wound. Necrotic tissue is dead tissue, and culturing it can lead to misleading results, as it may not reflect the current state of infection or the microorganisms causing the infection. Obtaining the sample from the outer edge of the wound is also not ideal. The outer edge of the wound may be contaminated with skin flora or other external contaminants, which can lead to inaccurate culture results. The sample should be taken from clean, viable tissue within the wound bed to ensure accurate identification of the microorganisms present. Applying sterile gloves to remove the outer dressing is the correct action. This step is crucial to maintain aseptic technique and prevent contamination of the wound and the specimen. Sterile gloves help ensure that the nurse does not introduce any external microorganisms into the wound while handling the dressing. Crushing the transport medium after obtaining the specimen is a necessary step to activate the medium and preserve the specimen during transport to the laboratory. However, this step comes after the specimen has been collected and does not directly relate to the technique of obtaining the specimen.
Question 3 of 5
A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by their provider. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale: Asking the provider is cautious but less proactive; pushing prescribed meds dismisses autonomy; the FDA doesn’t fully regulate TCM. Arranging a referral respects the client’s choice and facilitates safe exploration.
Question 4 of 5
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
Correct Answer: B
Rationale: Electrical wires secured to baseboards are generally not considered a significant fall risk. Properly secured wires reduce the likelihood of tripping hazards compared to loose or exposed wires.
Therefore, this is not a primary concern for fall risk. Taking antihypertensive medication can increase the risk of falls, especially in older adults. These medications can cause orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness and an increased risk of falling. This makes it a critical factor to consider in fall risk assessments. Wearing rubber-sole shoes is typically recommended to prevent falls because they provide good traction and reduce the risk of slipping. However, if the soles are too thick or bulky, they can catch on carpets or other surfaces, potentially causing trips. Generally, rubber-sole shoes are considered safer than other types of footwear. A visual acuity of 20/40 indicates some level of visual impairment, but it is not severe. While reduced visual acuity can contribute to fall risk, it is not as significant as the risk posed by medications that affect blood pressure. Visual impairments should still be addressed, but they are not the most immediate concern in this context.
Question 5 of 5
A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Edema and distended neck veins indicate fluid overload, not deficit. Postural hypotension occurs due to reduced blood volume, causing dizziness upon standing. Tachycardia, not bradycardia, is expected as a compensatory response to fluid loss.