ATI Fundamentals Proctored Exam Study Guide 3 -Nurselytic

Correct Answer: C

Rationale: The priority action for the nurse in this scenario is to evacuate the clients (
Choice
C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (
Choice
B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (
Choice
A) may put the nurse at risk and delay client evacuation. Closing doors (
Choice
D) may contain the fire but does not address the immediate need of client safety.

Correct Answer: D

Rationale: The correct answer is D. The 79 yo client post-op following below-the-knee amputation should be assigned to a room closest to the nursing station for fall prevention. This client may have mobility challenges, increased risk of falls due to recent surgery, and may require closer monitoring and immediate assistance if needed. Placing the client near the nursing station allows for quick response to any fall risk or postoperative complications.

A: The 43 yo client post-op following laparoscopic cholecystectomy is not at high risk for falls compared to the amputee.
B: The 61 yo client being admitted for telemetry to rule out MI does not necessarily have a higher fall risk than the amputee.
C: The 50 yo client post-op following open reduction internal fixation of ankle may have mobility limitations but is not as high risk for falls as the amputee.

Correct Answer: A

Rationale: The correct answer is A, complete fall-risk assessment. This is the priority action because it helps identify specific risks the client faces, allowing for tailored interventions to prevent falls. Educating the client and family (
B) is important but assessing risk comes first. Completing a physical assessment (
C) is also important but not the priority in this case. Surveying belongings (
D) is not as urgent as assessing the client's fall risk.

Correct Answer: B,C,E

Rationale:
Correct
Answer: B, C, E


Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.

Incorrect

Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,

Correct Answer: B

Rationale: The correct answer is B. This statement indicates a need for further teaching because it is not safe to leave a baby unattended in the bathtub even if they can sit up. Babies can easily slip or move unexpectedly, leading to a potential drowning risk. Teaching should emphasize the importance of constant supervision during bath time.
Choice A is incorrect as it highlights an unsafe practice of initiating swimming lessons too early for an infant.
Choice C demonstrates proper safety measures by testing water temperature.
Choice D shows awareness of removing potential hazards from the infant's environment.