ATI RN
ATI Leadership Practice A
1. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
- A. Droplet precautions
- B. Protective environment
- C. Airborne precautions
- D. Contact precautions
Correct answer: D
Rationale: The correct answer is D: Contact precautions. Contact precautions are used when there is a risk of transmission of infections through direct or indirect contact. In this scenario, the client has an abdominal wound with purulent drainage, indicating a potential for infection transmission through contact. Droplet precautions (choice A) are used for infections transmitted through respiratory droplets, such as influenza. Protective environment (choice B) is used for immunocompromised clients. Airborne precautions (choice C) are used for infections transmitted through small droplets that remain in the air, like tuberculosis. Therefore, in this case, the nurse should initiate contact precautions to prevent the spread of infection.
2. A nurse is reviewing prescriptions for a patient with major depression at the county clinic. Since the patient has a mild intellectual disability, the nurse would question which classification of antidepressant drugs:
- A. Selective serotonin reuptake inhibitors
- B. Monoamine oxidase inhibitors
- C. Serotonin and norepinephrine reuptake inhibitors
- D. All of the above
Correct answer: B
Rationale: Monoamine oxidase inhibitors are less suitable for patients with intellectual disabilities due to the need for dietary restrictions and close monitoring. These restrictions can be challenging for patients with mild intellectual disabilities to follow, making this drug class a concern for this patient population.
3. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
4. In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. When a client has a latex allergy, it is crucial to avoid direct contact with latex-containing products to prevent an allergic reaction. Choosing hypoallergenic latex gloves that are powder-free reduces the risk of the client being exposed to latex allergens. Option A is incorrect because using ethylene oxide for sterilization does not directly address the client's latex allergy. Option C is incorrect because cleansing latex ports with chlorhexidine does not eliminate the risk of latex exposure. Option D is incorrect as it does not specifically address the issue of latex allergy during the procedure.
5. In one of your home visit to Mr. JUN, you found out that his son is sick with cholera. There is a great possibility that other member of the family will also get cholera. This possibility is a/an:
- A. Foreseeable crisis
- B. Health threat
- C. Health deficit
- D. Crisis
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
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