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ATI Fundamentals
1. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?
- A. Speak to the client at a slower rate.
- B. Assist the client in using flash cards with pictures.
- C. Speak to the client in a loud voice.
- D. Give instructions one step at a time.
Correct answer: C
Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.
2. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
- A. 4,500/mm³
- B. 7,000/mm³
- C. 10,000/mm³
- D. 25,000/mm³
Correct answer: D
Rationale: Leukocytosis is defined as an increase in the total white blood cell count. A normal WBC count typically ranges from 4,500 to 10,000/mm³. A WBC count of 25,000/mm³, as indicated in choice D, is significantly higher than the normal range and clearly indicates leukocytosis.
3. What is the primary goal of performing a bed bath?
- A. To cleanse, refresh, and provide comfort to the client who must remain in bed
- B. To expose the necessary parts of the body
- C. To develop skills in bed bath
- D. To check the body temperature of the client in bed
Correct answer: A
Rationale: The primary goal of performing a bed bath is to cleanse, refresh, and provide comfort to clients who are unable to leave their bed. This helps maintain their hygiene, promotes skin health, and enhances their overall well-being. Choice B is incorrect as the primary purpose is not to expose body parts but to provide hygiene and comfort. Choice C is incorrect as the main goal is client care, not skill development. Choice D is incorrect as checking body temperature is not the main purpose of a bed bath.
4. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
- A. Prime IV tubing with 0.9% sodium chloride
- B. Use a 24-gauge IV catheter
- C. Obtain filterless IV tubing
- D. Place blood in the warmer for 1 hr
Correct answer: A
Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.
5. When discussing group treatment and therapy with a client, which characteristic should the nurse include as being a characteristic of a therapeutic group?
- A. The group is organized in an autocratic structure.
- B. The group encourages members to focus on a particular issue
- C. The group must be led by a licensed psychiatrist.
- D. The group encourages clients to form dependent relationships.
Correct answer: B
Rationale: In therapeutic groups, the focus is often on addressing specific issues or topics. This approach allows group members to concentrate on their concerns, share experiences, and work towards common goals. Autocratic structures, mandatory leadership by a licensed psychiatrist, or fostering dependent relationships are not typical characteristics of therapeutic groups.
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