ATI PN Fundamentals of Nursing 2020 with NGN Exam 2

Extract:

Question 1 of 5

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.

Order the Items

Source Container

Open the innermost lower flap of the sterile kit while standing away from the sterile field.

Open each side flap of the sterile kit individually while pulling to the side.

Open the outside cover of the sterile kit and remove the dust cover.

Grasp the outermost flap of the sterile kit while opening away from the body.

Prepare a dry work surface above the waist level.

Correct Answer: E,C,D,B,A

Rationale: E prepares the area, C opens the kit, D starts unfolding, B continues, and A accesses contents, maintaining sterility throughout.

Question 2 of 5

A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

A. Use direct quotes made by the client to describe the incident. B. Make a notation in the client's medical record that an incident report was completed. C. Draw a conclusion regarding the cause of the incident. D. Place a copy of the incident report in the client's medical record.

Correct Answer: A

Rationale: Direct quotes provide an objective account. Noting in the record, concluding causes, or filing copies mix purposes and may affect legal status.

Question 3 of 5

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

A. A family member is napping in the client's room. B. A client refuses to eat at mealtime C. A client's bed alarm is malfunctioning D. An assistive personnel is late for the upcoming shift

Correct Answer: C

Rationale: A malfunctioning bed alarm poses a safety risk, necessitating a report. Napping, refusal to eat, and lateness don't typically require one.

Question 4 of 5

A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, 'What should I do if I have difficulty breathing?' Which of the following responses should the nurse make?

A. Call me so that I can help you change your position. B. Try to close your eyes and get some sleep. C. It is common for breathing to become more difficult as time goes on. D. Therapy choices are limited for clients who do not want resuscitation.

Correct Answer: A

Rationale: Repositioning can ease breathing, offering practical help. Sleep doesn't address it, stating it's common lacks action, and limiting therapy dismisses comfort options.

Question 5 of 5

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

A. Avoid entering the client's room unless requested during the night. B. Turn off alarms on bedside monitoring equipment. C. Conduct staff communications away from the client's room. D. Turn on the client's TV to distract from hallway noise.

Correct Answer: C

Rationale: Moving staff talks reduces noise effectively. Avoiding checks risks safety, turning off alarms is unsafe, and TV adds noise.

ATI PN Fundamentals of Nursing 2020 with NGN Exam 2 | Nurselytic

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