ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
B: Wearing a mask within 3 ft of the client helps prevent the spread of pertussis through respiratory droplets.
C: Placing a surgical mask on the client during transportation helps contain respiratory secretions and prevent transmission.
E: Wearing a gown during care involving secretions protects the nurse from potential contamination.
Incorrect
Choices:
A: Negative air pressure isn't necessary for pertussis; it's more for airborne diseases like TB.
D: Sterile gloves are not required for handling soiled linens unless there is a specific infection control protocol in place.
Question 2 of 5
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
B: Nail polish should not be used near a client receiving oxygen as it is flammable and can ignite easily, posing a fire hazard.
C: A 'No smoking' sign should be placed on the front door to remind everyone that smoking is prohibited in the presence of oxygen, reducing the risk of fire.
E: A fire extinguisher should be readily available in the home to quickly extinguish any fire that may occur due to oxygen use, ensuring safety.
Incorrect
Choices:
A: Family members who smoke must be at least 10 ft from the client when oxygen is in use is important, but it is more crucial to prevent any source of ignition near oxygen.
D: Cotton bedding & clothing should not be replaced with items made from wool specifically due to oxygen use. It is unnecessary and not related to oxygen safety.
Question 3 of 5
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the medication, which of the following actions is the highest priority?
Correct Answer: C
Rationale: The correct answer is C: Identifying the client's medication allergies. Before administering any medication, it is crucial to identify if the client has any allergies to prevent adverse reactions. This step ensures the client's safety and well-being during the surgical procedure. Teaching the client about the medication (choice
A) is important but not as urgent as verifying allergies. Administering the medication (choice
B) can be done after ensuring safety. Documenting anxiety level (choice
D) is important for overall care but not as critical as identifying allergies.
Question 4 of 5
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (Bradypnea), which the nurse should monitor for. Orthostatic hypotension can occur due to the vasodilatory effects of opioids. Nausea is a common side effect of opioids due to their effect on the gastrointestinal system. Urinary incontinence and diarrhea are not typical adverse effects of opioid analgesia, so choices A and B are incorrect.
Question 5 of 5
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
Correct Answer: A, D
Rationale: Correct Answer Explanation: A nurse should keep the head of the bed elevated at 30 degrees to reduce pressure on the sacrum and coccyx, thus preventing pressure ulcers. Having the client sit on a gel cushion when in a chair helps distribute weight evenly and reduce pressure points. These interventions promote skin integrity by minimizing pressure and friction. Massage of bony prominences can increase the risk of pressure ulcers by causing friction and compromising blood flow. Applying cornstarch can create a moist environment, which can lead to skin breakdown. Repositioning the client at least every 3 hours helps to prevent pressure ulcers by relieving pressure points.