a nurse is administering medications to a group of clients which of the following occurrences requires the completion of an incident report a nurse is administering medications to a group of clients which of the following occurrences requires the completion of an incident report
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?

Correct answer: A

Rationale: The correct answer is A. When a client receives antibiotics 2 hours late, it constitutes a medication error, requiring the completion of an incident report. Choice B, a client vomiting within 20 minutes of taking medications, does not necessarily require an incident report unless it is suspected to be related to a medication error. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication an hour early, are not incidents that mandate the completion of an incident report unless there are specific circumstances indicating otherwise.

2. Which situation denotes a nontherapeutic nurse-patient-family relationship?

Correct answer: B

Rationale: Criticizing parents or making negative comments about their involvement is nontherapeutic and can damage the nurse-patient-family relationship.

3. In which disorder does a Staphylococcus aureus organism produce a toxin leading to exfoliation and large blister formation?

Correct answer: Herpes simplex I virus

Rationale: The correct answer is 'Herpes simplex I virus.' This disorder is known as Staphylococcal scalded skin syndrome (SSSS), where a Staphylococcus aureus organism produces an exfoliative toxin leading to skin exfoliation and large blister formation. Choices B, C, and D are incorrect. Herpes simplex viruses (I and II) cause different types of skin lesions and do not lead to exfoliation and blister formation. Necrotizing fasciitis is a severe soft tissue infection, while cellulitis is a bacterial skin infection that does not typically involve exfoliation and blister formation like in SSSS.

4. Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?

Correct answer: Excessive administration of chloride

Rationale:

5. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

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