ATI RN
ATI RN Fundamentals 2023 Exam 5 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: Clean from the incision to the surrounding skin. This instruction is crucial to prevent introducing any pathogens into the wound. Cleaning from the incision site outward helps minimize the risk of contamination. Option A is incorrect as changing the dressing too frequently can disrupt the wound healing process. Option B is incorrect as tincture of benzoin can cause skin irritation and is not recommended for incision sites. Option D is incorrect as sterile gloves are not necessary for routine dressing changes unless in a sterile environment.
Question 2 of 5
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A. Cranial nerve VII, the facial nerve, controls facial expressions including smiling. Symmetrical smile indicates intact function. B is incorrect as tongue position is assessed by cranial nerve XII. C is related to cranial nerve XI, not VII. D involves cranial nerve II, not VII. E, F, and G are not relevant to cranial nerve VII assessment. In summary, A is correct because it directly relates to the function of cranial nerve VII, while the other choices are unrelated or pertain to different cranial nerves.
Question 3 of 5
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
Correct Answer: B
Rationale: The correct answer is B: The client takes an antihypertensive medication. Antihypertensive medications can cause dizziness or orthostatic hypotension, increasing the risk of falls. Other choices are incorrect because: A: Secured wires are not a direct fall risk. C: Rubber-sole shoes may actually decrease fall risk by providing better traction. D: Visual acuity of 20/40 is suboptimal but not a direct fall risk.
Question 4 of 5
A nurse is caring for a client who has tuberculosis. The nurse should anticipate which isolation precautions for the client?
Correct Answer: A
Rationale: The correct answer is A: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Airborne precautions include wearing an N95 respirator mask, placing the client in a negative pressure room, and ensuring proper ventilation. Contact precautions (
C) are for diseases spread by direct contact, not airborne transmission like tuberculosis. Droplet precautions (
D) are for diseases spread through large droplets, not small droplet nuclei. Protective precautions (
B) are not specific to tuberculosis.
Question 5 of 5
During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first is D: Obtain the client's type and cross-match. This is the priority because ensuring that the client has the necessary blood products available for surgery is crucial for their safety. By obtaining the type and cross-match promptly, the nurse can address the oversight and prevent any potential harm to the client during the surgery.
Informing the provider (
A) can be done after obtaining the type and cross-match to update them on the situation. Documenting the incident (
B) in the client's medical record is important but should not take precedence over ensuring the client's safety. Similarly, preparing an incident report (
C) for risk management is important for quality improvement but can be done after addressing the immediate issue.