ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A,E
Rationale:
Correct Answer: A, E
Rationale:
A: Cutting the opening of the pouch 1/8 inch larger than the stoma prevents irritation and ensures a proper fit.
E: Emptying the pouch when it's one-third full prevents leakage and skin irritation.
Incorrect
Choices:
B: Placing gauze over the stoma can introduce fibers and cause irritation.
C: A purple-blue stoma color may indicate reduced blood flow, not healing.
D: Povidone-iodine can be irritating; mild soap and water are recommended.
Question 2 of 5
A nurse is planning care for a client who has a seizure disorder. Which of the following actions should the nurse include in the client's plan of care?
Correct Answer: C
Rationale: The correct answer is C: Keep suction equipment available in the client's room. During a seizure, a client may experience excessive secretions or vomiting, which can lead to airway obstruction. Having suction equipment readily available allows for prompt intervention to maintain a clear airway and prevent aspiration.
A: Having a padded tongue blade available is not recommended as it can cause injury during a seizure.
B: Keeping all four side rails down can restrict movement and potentially cause injury during a seizure.
D: Having wire cutters available is unnecessary and not relevant to managing a seizure.
Question 3 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action is to clear the nearby area of furniture (choice
C) during a seizure to prevent injury. Moving the client (choice
A) may worsen the seizure. Turning the client onto their back (choice
B) can lead to aspiration. Placing a tongue depressor in the mouth (choice
D) can cause airway obstruction. The other choices are irrelevant or potentially harmful.
Question 4 of 5
A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?
Correct Answer: A
Rationale: The correct answer is A: A client who has tuberculosis. Tuberculosis is an airborne disease caused by Mycobacterium tuberculosis. Placing a client with tuberculosis in airborne precautions is essential to prevent the transmission of the disease through the air. Airborne precautions include using a negative pressure room, wearing an N95 respirator mask, and ensuring proper ventilation.
Choice B: Pneumonia is typically transmitted through droplets, not airborne transmission.
Choice C: Shigella is transmitted through fecal-oral route, not airborne transmission.
Choice D: Strep throat is transmitted through respiratory droplets, not airborne transmission.
Therefore, choices B, C, and D do not require airborne precautions.
Question 5 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: The correct answer is C: Apply sterile gloves to remove the outer dressing. This is the correct action because it ensures that the nurse maintains a sterile field while obtaining the wound culture specimen. By applying sterile gloves, the nurse minimizes the risk of introducing contaminants to the wound, which could lead to inaccurate culture results or potential infection.
Choices A, B, and D are incorrect because:
A: Rotating the swab over necrotic tissue can introduce contaminants and compromise the accuracy of the culture results.
B: Obtaining the sample from the outer edge of the wound may not provide an accurate representation of the microbial flora present in the wound.
D: Crushing the transport medium after obtaining the specimen can lead to spillage and contamination of the specimen.
By choosing option C, the nurse follows proper sterile technique and ensures the integrity of the wound culture specimen.