ATI RN Fundamental Proctored Exam With NGN Graded -Nurselytic

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ATI RN Fundamental Proctored Exam With NGN Graded Questions

Extract:


Question 1 of 5

A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?

Correct Answer: A

Rationale:
Correct
Answer: A: Don't measure the client's temperature rectally.


Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa.
Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.

Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.

Question 2 of 5

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Rationale:

Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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