ATI PN Fundamentals 2023 Exam 4

Extract:

Question 1 of 5

A nurse is caring for a postoperative male client in the surgical unit. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Select all that apply

A. Respiratory rate 10/minB. Pulse oximetry 88% on room airC. Blood pressure 99/46 mm HgD. Morphine 10 mg administered subcutaneously

Correct Answer: A,B,D

Rationale: A: Low respiratory rate suggests opioid depression. B: Low SaO2 indicates hypoxemia. D: Morphine dose may need reassessment due to side effects.

Question 2 of 5

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

A. Stand with the crutch tips against the feet.B. Bear weight on the unaffected leg.C. Keep the crutches at the level of the axillae.D. Hold the arms straight when walking.

Correct Answer: B

Rationale: Weight on the unaffected leg is key to the three-point gait for stability.

Question 3 of 5

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

A. Inject air into the ampule prior to drawing the medication into a syringe.B. Add 0.5 mL of diluent to the medication.C. Use a filter needle to aspirate the medication.D. Cleanse the tip of the ampule with an alcohol swab after opening.

Correct Answer: C

Rationale: Using a filter needle ensures no glass contaminants are administered.

Question 4 of 5

A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

A. A client whose grief response is repressed.B. A client whose grief response begins following a terminal diagnosis.C. A client whose grief response leads to self-destructive behaviors.D. A client whose grief response is triggered by a secondary loss.

Correct Answer: C

Rationale: Exaggerated grief involves intense, harmful reactions like self-destructive behaviors, impairing function.

Question 5 of 5

A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

A. Isopropyl alcohol.B. Hydrogen peroxide.C. Chlorhexidine gluconate.D. Chlorine bleach.

Correct Answer: D

Rationale: Chlorine bleach effectively kills bloodborne pathogens like HIV and hepatitis B.

ATI PN Fundamentals 2023 Exam 4 | Nurselytic

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