Questions 38

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ATI RN Test Bank

ATI NUR 104 Final Assessment Fundamentals Questions

Extract:

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?


Question 1 of 5

Provide a schedule of visiting hours to the client's family

Correct Answer: D

Rationale: Documenting allergies is critical to prevent adverse reactions, taking priority over family schedules, care planning, or teaching.

Extract:

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?


Question 2 of 5

Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side

Correct Answer: C

Rationale: Tapping the bottom and breaking the top away from the body with gauze minimizes injury and contamination. Other methods risk glass shards or unsafe handling.

Extract:

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?


Question 3 of 5

Identifying the client by name when making a referral for home health services

Correct Answer: B

Rationale: Reporting lab findings to family without consent violates confidentiality. Referrals, discussions with the nurse manager, and provider notifications are permissible for care coordination.

Extract:

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?


Question 4 of 5

Nausea

Correct Answer: A

Rationale: Nausea is subjective, reported by the client. Petechiae, blood pressure, and cyanosis are objective, observable, or measurable.

Extract:

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?


Question 5 of 5

Explain the risks and benefits of the procedure

Correct Answer: B

Rationale: The nurse witnesses the client’s signature, confirming voluntary consent. Explaining risks, obtaining consent, or explaining the procedure is the provider’s role.

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