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ATI Fundamentals
1. A client has experienced a right-hemispheric stroke. Which of the following is not an expected finding?
- A. Impulse control difficulty
- B. Left hemiplegia
- C. Loss of depth perception
- D. Aphasia
Correct answer: D
Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.
2. What should be done in order to prevent contamination of the environment when making a bed?
- A. Avoid flinging soiled linens
- B. Strip all linens at the same time
- C. Finish both sides at the same time
- D. Embrace soiled linen
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.
3. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?
- A. Hormones
- B. Secretion
- C. Immunity
- D. Glands
Correct answer: C
Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.
4. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?
- A. Store the glasses in a labeled case.
- B. Clean the glasses with hot water
- C. Clean the glasses with a paper towel.
- D. Store the glasses on the bedside table.
Correct answer: A
Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.
5. 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.
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