ATI RN
ATI Nurs100102 Fundamentals Retake Questions
Extract:
Question 1 of 5
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Answer D is correct because consuming ice chips can significantly lower oral temperature readings. Waiting for 30 minutes allows the client's oral temperature to normalize after the ice chips consumption, providing a more accurate measurement.
Choice A is incorrect because warm water may not be effective in quickly neutralizing the temperature effects of the ice chips.
Choice B is incorrect as it does not address the issue or provide a solution.
Choice C is incorrect as it can give a falsely low reading due to the ice chips.
Question 2 of 5
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
Correct Answer: A
Rationale: The correct answer is A:
To identify delayed gastric emptying. Measuring gastric residual helps determine if the stomach is emptying properly, indicating if the client is tolerating the feedings. This is crucial to prevent complications like aspiration.
Choice B is incorrect because measuring gastric residual does not remove gastric acid.
Choice C is incorrect as it does not directly assess electrolyte balance.
Choice D is incorrect because verifying NG tube placement is typically done through other methods like x-ray.
Question 3 of 5
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Secure the restraints using a quick-release tie. This is essential for patient safety in case of emergency situations requiring quick removal.
Choice A is incorrect as securing restraints to the lowest bar can lead to entanglement.
Choice C is incorrect as having four fingers fit under the restraint does not ensure proper fit.
Choice D is incorrect as restraints should be removed every 2 hours, not 4.
Question 4 of 5
A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?
Correct Answer: D
Rationale: The correct answer is D: Gloves. Removing gloves first is crucial to prevent the spread of contamination. By removing gloves first, the nurse ensures that any potential pathogens on the gloves do not transfer to other PPE items or the nurse's skin. If the nurse were to remove the gown, face shield, or mask first, there is a risk of contamination spread to the hands, which can then spread to the face or clothing during subsequent removal of other PPE items. Removing gloves first reduces this risk and follows the standard protocol for PPE doffing. Removing the gown, face shield, or mask before the gloves would increase the risk of contamination and compromise infection control measures.
Question 5 of 5
A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?
Correct Answer: C
Rationale: The correct answer is C: Contact precautions. This is the appropriate type of precaution for a client with VRE, as the bacteria are spread through direct contact with the infected wound or contaminated surfaces. Contact precautions involve wearing gloves and a gown when providing care to prevent transmission. Airborne precautions (choice
A) are for diseases spread through tiny particles in the air, like tuberculosis. Protective precautions (choice
B) are used for immunocompromised clients. Droplet precautions (choice
D) are for diseases spread through respiratory droplets, like the flu.
Therefore, choice C is the most appropriate in this scenario.