ATI RN
RN-ATI-Fundamentals-of-Nursing-2023-2024 Questions
Extract:
Question 1 of 5
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
Correct Answer: A
Rationale: The correct answer is A because removing the cap and placing it sterile-side up on a clean surface helps maintain the sterility of the solution. Placing the cap sterile-side up prevents contamination of the inside of the cap. This action ensures that the contents of the bottle remain sterile while allowing easy access to the solution during the procedure.
In contrast, option B is incorrect because placing sterile gauze over spilled solution within the sterile field may introduce non-sterile material into the field. Option C is incorrect as holding the bottle in the center of the sterile field may increase the risk of accidental contamination. Option D is incorrect because holding the irrigation solution bottle with the label facing away from the palm of the hand does not ensure the sterility of the solution.
Question 2 of 5
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. In clients receiving magnesium sulfate for preeclampsia, monitoring deep tendon reflexes is crucial as magnesium sulfate can lead to muscle weakness and decreased reflexes, indicating potential toxicity. Monitoring for 2+ reflexes ensures the client is within the therapeutic range. Pulse rate (
B) and urine output (
C) are important to monitor but are not specific therapeutic effects of magnesium sulfate. Proteinuria (
D) is a sign of preeclampsia and not a therapeutic effect of the medication.
Question 3 of 5
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is the most appropriate action to evaluate the effectiveness of the paracentesis. Paracentesis is a procedure to remove fluid from the abdominal cavity. By comparing the client's current weight with the preprocedure weight, the nurse can assess the amount of fluid removed and determine the effectiveness of the procedure in relieving ascites, a common complication of end-stage liver disease. Checking for leakage at the site of the procedure is important for immediate post-procedure assessment but does not evaluate the effectiveness of the procedure. Confirming that the client is able to urinate is important for assessing kidney function but does not directly evaluate the effectiveness of the paracentesis. Checking the client's serum albumin levels is important for assessing liver function but does not specifically evaluate the effectiveness of the procedure in removing fluid.
Question 4 of 5
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is important because high flow rates can lead to oxygen toxicity. Nasal cannula at 6 L/min is a common practice to ensure adequate oxygen delivery without causing harm.
Choice A is incorrect because the ball inside the flow meter is not used to regulate oxygen flow.
Choice C is incorrect as the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen supply.
Choice D is incorrect because petroleum jelly should not be used near oxygen equipment due to flammability risks.
Question 5 of 5
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets. Droplet precautions involve wearing a mask to prevent the spread of droplets when in close contact with the client. Contact precautions are used for diseases transmitted by direct physical contact. Airborne precautions are for diseases spread through tiny particles that remain suspended in the air. Protective precautions are not specific to any particular mode of transmission.