ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Ask the client if she is having pain. The elevated blood pressure reading could be attributed to pain and anxiety related to the fractured femur. By assessing if the client is in pain, the nurse can address the root cause of the high blood pressure. Requesting antihypertensive or anti-anxiety medication without evaluating the client's pain level would not address the underlying issue. Simply rechecking the blood pressure without addressing the potential pain would not provide a solution. Asking about pain is the initial step in managing the client's elevated blood pressure in this context.
Question 2 of 5
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Restlessness is an early indication of hypoxemia because the body is trying to compensate for decreased oxygen levels. Tachypnea (rapid breathing) is the body's response to hypoxemia to increase oxygen intake. Pallor is a sign of decreased oxygen saturation in the blood. Bradycardia and confusion are not typically early signs of hypoxemia, as the body usually increases heart rate to compensate for low oxygen levels, and confusion is a later sign indicating severe hypoxemia.
Question 3 of 5
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
B: Nail polish should not be used near a client receiving oxygen as it is flammable and can ignite easily, posing a fire hazard.
C: A 'No smoking' sign should be placed on the front door to remind everyone that smoking is prohibited in the presence of oxygen, reducing the risk of fire.
E: A fire extinguisher should be readily available in the home to quickly extinguish any fire that may occur due to oxygen use, ensuring safety.
Incorrect
Choices:
A: Family members who smoke must be at least 10 ft from the client when oxygen is in use is important, but it is more crucial to prevent any source of ignition near oxygen.
D: Cotton bedding & clothing should not be replaced with items made from wool specifically due to oxygen use. It is unnecessary and not related to oxygen safety.
Question 4 of 5
A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
B: Wearing a mask within 3 ft of the client helps prevent the spread of pertussis through respiratory droplets.
C: Placing a surgical mask on the client during transportation helps contain respiratory secretions and prevent transmission.
E: Wearing a gown during care involving secretions protects the nurse from potential contamination.
Incorrect
Choices:
A: Negative air pressure isn't necessary for pertussis; it's more for airborne diseases like TB.
D: Sterile gloves are not required for handling soiled linens unless there is a specific infection control protocol in place.
Question 5 of 5
A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all.
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E. Reporting communicable & infectious diseases is crucial for planning and evaluating control & prevention strategies to contain the spread of the disease. It helps determine public health priorities by allocating resources accordingly. Reporting also ensures proper medical treatment for affected individuals to prevent complications and further transmission. Additionally, monitoring for common-source outbreaks allows for timely intervention to prevent widespread infections.
Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable & infectious diseases.