ATI RN
ATI Nurs100102 Fundamentals Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?
Correct Answer: A
Rationale: The correct answer is A: Mask. When caring for a client under droplet precautions, the nurse should wear a mask to prevent the spread of respiratory droplets. This helps protect both the nurse and the client from potential infections, such as influenza or COVID-19. Gloves (
B) are worn for contact precautions, goggles (
C) are used for protection against splashes, and a gown (
D) is typically worn for contact precautions as well. In this scenario, the main concern is respiratory droplet transmission, making a mask the most appropriate choice.
Question 2 of 5
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
Correct Answer: C
Rationale: The correct answer is C: 0.45% sodium chloride. This solution, also known as half-normal saline, is hypotonic and helps to dilute the excess sodium in hypernatremia. It slowly corrects the sodium imbalance without causing a rapid shift in serum osmolality, reducing the risk of cerebral edema.
A: Dextrose 5% in 0.9% sodium chloride is isotonic and may worsen hypernatremia by increasing sodium levels.
B: Lactated Ringer's contains sodium and will not effectively lower serum sodium levels in hypernatremia.
D: Dextrose 10% in water is hypertonic and can further increase serum osmolality, exacerbating hypernatremia.
Choosing solution C is the most appropriate intervention to safely correct the hypernatremia without causing complications.
Question 3 of 5
A nurse has completed an informed consent form with a client. The client then states, 'I have changed my mind and do not want to have the procedure done.' Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale:
1. Ethical Principle: Respect for Autonomy - The client has the right to make decisions about their own care.
2. Legal Principle: Withdrawal of consent is a legal right - The client can revoke consent at any time.
3. Nurse's Responsibility: Advocate for the client's wishes - It is the nurse's duty to respect the client's decision.
4. Patient Safety: Continuing against the client's wishes could lead to legal and ethical issues.
Summary of other choices:
B: Proceeding without consent violates the client's autonomy and legal rights.
C: While the form is legally binding, the client's right to revoke consent supersedes this.
D: Canceling the surgery without the client's explicit request could lead to legal repercussions.
Question 4 of 5
A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,C,D
Rationale: The correct actions are A,C, and D. A: Shaving in the direction of hair growth prevents skin irritation. C: Checking for personal items ensures client comfort and safety. D: Bath water temperature between 43.3-46.1°C prevents burns. B: Washing extremities from proximal to distal is incorrect as it disrupts circulation. E: Placing a gown on the strongest arm first may not be necessary for hygiene care for an immobile client.
Question 5 of 5
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Apply the bag for 30 minutes at a time. This is the correct action as prolonged exposure to cold can lead to tissue damage. Applying the ice bag for 30 minutes allows for therapeutic benefits without risking harm.
Choice A is incorrect as placing the bag directly on the skin can cause frostbite.
Choice B is incorrect as leaving air inside the bag reduces its contact with the skin, decreasing the effectiveness of the cold application.
Choice D is incorrect as reapplying the bag too soon can also lead to tissue damage.