before rigor mortis occurs the nurse is responsible for
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023 Quizlet

1. Before rigor mortis occurs, what is the nurse responsible for?

Correct answer: B

Rationale: Before rigor mortis occurs, the nurse is responsible for placing a pillow under the body's head and shoulders. This action helps maintain proper positioning, prevent postmortem changes, and ensure a dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically performed after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the immediate need for proper positioning before rigor mortis occurs.

2. Which action would break sterile technique while preparing a sterile field for a dressing change?

Correct answer: B

Rationale: Touching the outside wrapper of sterilized material without sterile gloves can introduce contaminants and compromise the sterility of the item. It is crucial to maintain strict adherence to sterile technique to prevent infections and ensure patient safety during procedures.

3. During a Romberg test, the patient is asked to assume which position?

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

4. Which of the following blood tests should be performed before a blood transfusion?

Correct answer: B

Rationale: Before administering a blood transfusion, it is crucial to perform blood typing and cross-matching to ensure compatibility between the donor's blood and the recipient's blood. This process helps prevent adverse reactions such as transfusion reactions, which can be life-threatening. Prothrombin and coagulation time, bleeding and clotting time, as well as CBC and electrolyte levels are important tests in other clinical contexts, but for blood transfusions, blood typing and cross-matching are essential to ensure patient safety.

5. A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?

Correct answer: C: Monitor vital signs.

Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.

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