ATI Fundamental Proctored Exam Study Guide 2024-2025 -Nurselytic

Questions 91

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ATI Fundamental Proctored Exam Study Guide 2024-2025 Questions

Extract:


Question 1 of 5

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?

Correct Answer: D

Rationale: The correct answer is D: Risk for injury. The patient's confusion and behavior of trying to get out of bed and pulling at the IV tubing indicate a potential risk for self-injury. Confusion can lead to falls or accidents, and pulling at the IV tubing can cause dislodgement leading to infection or inadequate medication delivery. The nurse's priority is to prevent harm to the patient.
Other choices are incorrect because:
A: Impaired home maintenance focuses on the patient's ability to maintain a safe and healthy home environment, not applicable in this acute care setting.
B: Deficient knowledge pertains to lack of understanding about a health condition or treatment, not relevant to the immediate safety concern.
C: Risk for poisoning does not align with the current scenario of potential physical harm due to the patient's confused behavior.

Question 2 of 5

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

Correct Answer: A

Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes.


Rationale:
1. Priority: Safety of the patient is the top priority, as the patient is at risk for injury due to attempts to remove essential medical devices.
2. Regular monitoring: Checking on the patient every 15 minutes allows for timely intervention if the patient attempts to remove the oxygen cannula or urinary catheter.
3. Prevention of harm: By checking frequently, nurses can prevent potential harm such as hypoxia or catheter-related complications.
4. Immediate action: This intervention addresses the immediate safety concern and ensures the patient's well-being.

Incorrect choices:
B: Risk for suffocation: Placing a sign does not directly address the patient's behavior.
C: Disturbed body image: Patient's behavior is not related to body image concerns.
D: Deficient knowledge: Explaining the purpose does not address the immediate safety risk.

Question 3 of 5

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?

Correct Answer: B

Rationale:
Correct
Answer: B - Deficient knowledge


Rationale: The nurse's assessment indicates that the patient lacks the knowledge to properly apply the sequential compression devices, leading to them being put on upside down. This nursing diagnosis reflects the patient's need for education on device application to prevent potential harm.

Summary of other choices:
A: Risk for falls - Not directly related to the incorrect application of sequential compression devices.
C: Risk for suffocation - Not relevant to the situation described.
D: Impaired physical mobility - Incorrect application of devices does not necessarily indicate impaired physical mobility.

Question 4 of 5

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?

Correct Answer: A

Rationale: The correct order is A: Pull the alarm. In case of a fire, alerting others is the first priority to ensure everyone's safety. This step will notify the fire department and initiate evacuation procedures. Removing the patient (
B) should be done after sounding the alarm to prevent harm. Using the fire extinguisher (
C) comes after ensuring the alarm is activated. Closing doors and windows (
D) is important to contain the fire but should be done after alerting others and removing the patient.

Question 5 of 5

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

Correct Answer: D

Rationale:
Correct
Answer: D - If my grandchild eats a plant.


Rationale:
- Eating some plants can be toxic to a child, so it is important to seek medical help immediately.
- Plants can cause serious harm and even be fatal if ingested.
- The other options emphasize important safety measures: calling poison control, not inducing vomiting, and seeking emergency help if the child loses consciousness.
- Providing syrup of ipecac is outdated and not recommended anymore due to potential risks.
- Calling 911 is crucial in emergencies, but the immediate concern with plants is to seek medical advice first.

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