ATI RN
ATI RN Fundamentals 2019 with NGN - Exam 2 Questions
Extract:
Question 1 of 5
A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Clean gloves, not sterile, are used to remove old dressings. The sterile field should be opened before donning sterile gloves to maintain sterility. Alcohol-based solutions are not typically used for wound cleansing. Sterile drapes should surround, not cover, the wound. Opening the sterile field after donning gloves ensures a sterile environment.
Question 2 of 5
A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Hand hygiene with alcohol-based rub before contact reduces infection risk in immunocompromised clients. Semiprivate rooms increase exposure, masks may not be sufficient, and sterile gloves are unnecessary for routine perineal care.
Question 3 of 5
A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Discrepancies should be reported before administration. Wasted controlled substances should be disposed of per facility policy, not in a sharps container. The count should be verified before removing the dose. Asking a second nurse to witness and sign for wasted portions ensures accountability and compliance with regulations.
Question 4 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: Stopping the transfusion, placing the client in high-Fowler's position, obtaining a diuretic prescription, and administering oxygen manage transfusion-associated circulatory overload (TACO). Epinephrine is for anaphylaxis, not TACO.
Question 5 of 5
A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The client should be positioned 6.1 m (20 feet) away from the chart, not 3.3 m (10 feet). The nurse should document the smallest line the client can read on the chart, not the largest line. The nurse should instruct the client to begin the assessment with one eye covered, not both eyes open. The nurse should begin by testing the client while they are wearing glasses because this is how the client normally sees.