ATI RN
ATI Fundamentals Proctored Exam 2023
1. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?
- A. Remove the protective gown after leaving the client's room.
- B. Place the client in a room with negative pressure.
- C. Wear gloves when providing care to the client.
- D. Wear a mask when in the client's room.
Correct answer: C
Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.
2. When administering digoxin 0.125 mg PO to an adult client, for which of the following findings should the nurse report to the provider?
- A. Potassium level 4.2 mEq/L.
- B. Apical pulse 58/min
- C. Digoxin level 1 ng/mL
- D. Constipation for 2 days
Correct answer: C
Rationale: Monitoring the digoxin level is crucial as it helps determine the drug's effectiveness and potential toxicity. A digoxin level of 1 ng/mL is within the therapeutic range. However, levels above this range can lead to toxicity, causing adverse effects like nausea, vomiting, visual disturbances, and dysrhythmias. Therefore, the nurse should report a digoxin level of 1 ng/mL to the provider for further evaluation and potential dose adjustment.
3. A client is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
- A. Cleanse equipment before removal from the client's room.
- B. Limit the client's visitors to 30 minutes per day.
- C. Discard the client's linens in a double bag.
- D. Discard the radioactive source in a biohazard bag
Correct answer: D
Rationale: When caring for a client receiving brachytherapy, it is crucial to handle radioactive sources appropriately. Discarding the radioactive source in a biohazard bag is essential to prevent exposure to radiation. Cleaning equipment before removal, limiting client's visitors, or discarding linens in a double bag are not specific to the management of radioactive sources in brachytherapy.
4. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?
- A. Instill 500 ml of solution through the NG tube.
- B. Insert a large-bore NG tube.
- C. Use a cold irrigation solution.
- D. Instruct the client to lie on their right side.
Correct answer: B
Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.
5. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
- A. Place the client's left arm on a pillow while he is sitting.
- B. Provide total care in assisting with the client's ADLs.
- C. Encourage mobility and avoid bed rest.
- D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.
Correct answer: A
Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.
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