ATI PN Fundamentals 2023

Extract:

Question 1 of 5

A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?

A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.B. The sterile solution is poured with the bottle held over the field.C. Unnecessary sterile items are placed on the field.D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.

Correct Answer: B

Rationale: Pouring over the field risks contamination from the bottle.

Question 2 of 5

A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

A. Postpone the procedure until the staff contacts the guardian.B. Obtain consent from the client.C. Prepare the client for surgery with implied consent.D. Request that the provider sign the consent form.

Correct Answer: C

Rationale: In emergencies, implied consent is appropriate when the guardian is unavailable.

Question 3 of 5

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?

A. Return the medication to the medication cabinet.B. Notify the provider of the client's refusal.C. Document the refusal in the client's medical record.D. Inform the client of the potential consequences of their refusal

Correct Answer: D

Rationale: Informing about consequences first respects autonomy and may encourage compliance.

Question 4 of 5

A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?

A. Not receiving blood will slow down your recovery.B. I understand that you decided not to receive blood products.C. You need to talk with your doctor about this.D. Why are you refusing to receive blood products?

Correct Answer: B

Rationale: Acknowledging the client's decision respects their autonomy and opens a dialogue.

Question 5 of 5

A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A. Administering vaginal cream to a client who has a vaginal infectionB. Providing postmortem care for a client who has just diedC. Suctioning a tracheostomy for a client who has a recent head injuryD. Changing a peripheral IV dressing for a client who is postoperative

Correct Answer: B

Rationale: Postmortem care is within the AP's scope; medication administration and invasive procedures are not.

ATI PN Fundamentals 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN