ATI RN
RN Comprehensive Online Practice 2019 B with NGN Questions
Extract:
Question 1 of 5
A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
Correct Answer: D
Rationale:
Correct
Answer: D - "I will be checking you once with your eyes open and once with them closed."
Rationale: The Romberg test assesses a person's ability to maintain balance with eyes open and closed, evaluating proprioception. This statement informs the client about the procedure accurately.
Summary:
A: Incorrect - Feet should be together, not apart.
B: Incorrect - Hands should be at the sides, not on hips.
C: Incorrect - The nurse should be close to the client for safety.
Question 2 of 5
During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
Correct Answer: D
Rationale: The correct answer is D: Move the client to a room near the nurses' station. This action ensures close monitoring of the client by staff, enhancing safety for both the client and healthcare providers. Proximity to the nurses' station allows for quick intervention if the client becomes combative or disoriented again. Keeping the client's television on or inserting a urinary catheter are not appropriate interventions for managing a disoriented and combative client. Consulting the provider for a mild sedative should be considered only after other supportive measures have been implemented.
Question 3 of 5
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Proceed with provision of medical care. In emergency situations where a patient is unconscious and family consent cannot be obtained, the nurse has a duty to provide necessary medical care to ensure the patient's safety and well-being. This is based on the principle of beneficence, which prioritizes the patient's best interests. Contacting the ethics committee (option
A) may cause unnecessary delays, obtaining consent from the employer (option
B) is inappropriate, and limiting care to comfort measures (option
C) may not address the underlying medical issue.
Therefore, proceeding with medical care (option
D) is the most ethically sound action to take in this scenario.
Question 4 of 5
A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
Correct Answer: D
Rationale: The correct answer is D: Ask the partner to list specific concerns. This is the first step the charge nurse should take to address the partner's complaint effectively. By asking for specific concerns, the nurse can gather detailed information about the perceived inadequacies in care. This will help the nurse understand the partner's perspective and identify the root cause of the issue. It also demonstrates active listening and empathy, which can help in building trust and improving communication.
Choice A is incorrect because evaluating changes requested by the partner without understanding the specific concerns may not address the underlying issues.
Choice B is incorrect because reviewing the client's plan of care before knowing the specific concerns may not be the most efficient approach.
Choice C is incorrect as analyzing other reports of poor care is premature without first addressing the partner's concerns directly.
Question 5 of 5
A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
Correct Answer: B
Rationale: The correct answer is B: Time the medication was given. Documenting the time the medication was given is crucial for tracking the effects of the incorrect dose and providing appropriate follow-up care. It helps in monitoring the client's response and planning interventions.
- A: Completion of the incident report is important for internal review but does not directly impact client care.
- C: Reason for the medication error should be documented in the incident report, not in the client's medical record.
- D: Notification of the pharmacist is essential but is not relevant to be documented in the client's medical record.