ATI RN
ATI Fundamental Proctored Exam Simulated Exam Questions With Detailed Verified Answer Questions
Extract:
Question 1 of 5
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the incision site. Sterile gloves help maintain asepsis during the dressing change, reducing the risk of contamination. Changing the dressing four times per day (
A) may disrupt the wound healing process by removing necessary protective barriers. Applying tincture of benzoin (
B) can cause skin irritation and is unnecessary for routine dressing changes. Cleaning from the incision to the surrounding skin (
D) can introduce microorganisms from the surrounding skin to the incision site, increasing infection risk.
Question 2 of 5
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
Correct Answer: A
Rationale:
Correct
Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration.
Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect
Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
Question 3 of 5
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice.
Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses.
Therefore, they are incorrect options.
Question 4 of 5
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line.
Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (
A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (
B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (
D) is not necessary as they can be mixed in the same solution.
Question 5 of 5
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
Correct Answer: A, B,E
Rationale: The correct answers are A, B, and E. Comparing the medication administration record against the container before removing the medication ensures accuracy. Before selecting the container, the nurse confirms the correct medication. At the client's bedside, the nurse verifies the medication before administration to prevent errors.
Choice C is incorrect because documentation should occur after administration.
Choice D is incorrect as medication reconciliation is not part of client education.