a client had oral surgery following a motor vehicle accident the nurse assessing the client finds the skin flushed and warm which of the following wou
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ATI RN

ATI Fundamentals Proctored Exam 2023 Quizlet

1. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

2. All of the following statements are true about donning sterile gloves except:

Correct answer: D

Rationale: When donning sterile gloves, it is essential to maintain sterility. The correct way to don sterile gloves includes grasping the outside of the cuff to put on the first glove and inserting the gloved fingers under the cuff outside the glove to put on the second glove. Adjustments should be made by sliding the fingers under the sterile cuff. It is crucial to remember that once the inside of the glove is touched during the donning process, it is no longer considered sterile.

3. What should be done in order to prevent contamination of the environment when making a bed?

Correct answer: A

Rationale: The correct practice to prevent contamination of the environment when making a bed is to avoid flinging soiled linens. Flinging soiled linens can spread contaminants in the environment, leading to potential health risks. By handling soiled linens properly and avoiding flinging them, the risk of contamination is minimized, ensuring a safer and cleaner environment. Stripping all linens at the same time (choice B) may not necessarily prevent contamination if the soiled linens are flung around. Finishing both sides at the same time (choice C) is unrelated to preventing contamination. Embracing soiled linen (choice D) is not hygienic and can lead to spreading contaminants.

4. A healthcare provider is reviewing the laboratory report of a client who has been taking lithium carbonate for the past 12 months. The provider notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the healthcare provider expect?

Correct answer: D

Rationale: A lithium level of 0.8 mEq/L falls within the therapeutic range for maintaining the drug's effectiveness while minimizing toxicity. Therefore, the appropriate action would be to continue administering the medication as prescribed by the healthcare provider to maintain the therapeutic effect for the client.

5. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

Correct answer: C

Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.

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