ATI RN
ATI RN Fundamentals 2019 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, 'I trust my doctor, but I don't understand what is meant by resecting my intestines.' Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Notify the provider. The nurse should notify the provider because the client has expressed confusion about the surgical procedure, which indicates a lack of informed consent. The provider needs to clarify the procedure with the client to ensure they fully understand the risks and benefits before proceeding with surgery. Providing brochures (
A) may not address the client's specific concerns. Completing an incident report (
B) is not necessary unless there was harm caused. Describing the surgery to the client (
D) should be done by the provider to ensure accurate information.
Question 2 of 5
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Cover the area of percussion with a towel. This is done to prevent skin irritation or damage during the percussion. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is essential to protect the skin from potential harm. By covering the area with a towel, the nurse ensures that the client's skin is not directly exposed to the force of the percussion, reducing the risk of injury. This step is crucial in maintaining the client's comfort and safety during the procedure.
Choice B is incorrect because postural drainage is typically done before meals to prevent aspiration.
Choice C is incorrect as clients should be instructed to breathe normally during vibration, not exhale quickly.
Choice D is incorrect as percussion is usually performed over the chest, not the lower back.
Question 3 of 5
A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct
Answer: D
Rationale:
1. Asking a second nurse to record her signature when wasting any unused portion ensures accountability and prevents diversion.
2. This practice follows the principles of the "two-person integrity rule" for controlled substances.
3. Verifying the count total after removing the amount needed (Option
A) is important but not specifically related to wasting the unused portion.
4. Placing the wasted portion in the sharps container (Option
B) is incorrect as controlled substances should be properly wasted and documented, not mixed with other waste.
5. Reporting any discrepancy in the count total (Option
C) is essential but does not address the specific step of having a second nurse witness the wasting process.
Question 4 of 5
A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. During the alarm reaction stage of the general adaptation syndrome, the body activates the fight-or-flight response. This includes the release of adrenaline, which causes the pupils to dilate to improve vision and alertness. Depression (choice
A) is not a typical manifestation of the alarm reaction stage. Bradycardia (choice
C) refers to a slow heart rate, which is not characteristic of the increased heart rate seen in the alarm reaction stage. Physical exhaustion (choice
D) typically occurs in the exhaustion stage, not the alarm reaction stage.
Question 5 of 5
A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first?
Correct Answer: D
Rationale: The correct answer is D: Determine whether the client can afford the insulin administration supplies. This should be completed first because even if the client has a prescription for insulin, if they cannot afford the supplies needed for administration, it will impact their ability to manage their diabetes effectively. Ensuring affordability is crucial for medication adherence and overall health outcomes.
Choice A is incorrect because making a copy of the medication reconciliation form is important but not the priority in this scenario.
Choice B is incorrect as obtaining printed information about insulin self-administration is important but can be done after ensuring the client can afford the supplies.
Choice C is incorrect as providing the client with a contact number for a diabetes education specialist is helpful but not as urgent as assessing affordability.
In summary, determining affordability of insulin supplies is the first step to ensure the client can effectively manage their diabetes.