ATI RN
ATI Nurs100102 Fundamentals Retake Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale: The correct answers are A, B, C, and E. Ignoring the urge to defecate can lead to stool hardening, causing constipation. Inadequate fluid intake can result in hard, dry stools. Decreased fiber in the diet can lead to slower digestion and difficulty passing stool. Excessive laxative use can cause dependency and worsen constipation. Increased activity (choice
D) is actually a potential remedy for constipation as physical activity can promote bowel movements. The other choices (F and G) are not relevant causes of constipation.
Question 2 of 5
The nurse is preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items should the nurse plan to use? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct PPE items for changing linens on a client with a draining sacral wound infected by MRSA are gown, surgical mask, and gloves. A gown will protect the nurse's clothing from contamination. A surgical mask will prevent inhaling infectious particles. Gloves will prevent direct contact with contaminated fluids. Shoe covers are not necessary for this task as the focus is on protecting the upper body and hands. An N95 respirator is not needed unless performing a procedure that generates aerosols.
Question 3 of 5
A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
Correct Answer: D
Rationale: The correct answer is D: "I will clean and dry the area before applying the patch." This is correct because ensuring the skin is clean and dry before applying the transdermal patch helps improve adherence and absorption. It also reduces the risk of skin irritation and infection.
A: "I will use lotion on irritated skin before applying a new patch in that area." - Incorrect, as using lotion on irritated skin may interfere with patch adherence and absorption.
B: "I will remove the old patch and apply a new one in the same location." - Incorrect, as patches should be applied to different sites to prevent skin irritation.
C: "I will press the patch securely in place on my forearm." - Incorrect, as while pressing the patch securely is important, it is not the only step needed for proper application.
Question 4 of 5
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Assess the apical pulse for a full minute. The nurse should assess the apical pulse for a full minute because an irregular radial pulse may indicate an underlying cardiac arrhythmia. By assessing the apical pulse at the apex of the heart, the nurse can more accurately detect irregularities in the heart rhythm. This prolonged assessment allows for a more comprehensive evaluation of the client's cardiac status.
Other choices are incorrect because:
A: Assessing the pedal pulses with a Doppler device is not necessary when dealing with an irregular radial pulse.
C: Assessing the apical pulse with a Doppler device is not the most appropriate action when irregularities are noted in the radial pulse.
D: Assessing the pedal pulses for a full minute does not directly address the issue of an irregular radial pulse.
Question 5 of 5
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?
Correct Answer: C
Rationale: The correct answer is C: Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. This step is crucial to prevent contamination of the culture sample with external microorganisms. Using saline irrigation helps remove debris, bacteria, and other contaminants from the wound surface, providing a more accurate culture result. Swabbing an area away from the wound (
A) or including intact skin at the wound edges (
D) would not provide a sample of the wound drainage itself. Irrigating the wound with an antiseptic (
B) may interfere with the accuracy of the culture results by killing the bacteria that need to be identified.