ATI FUNDAMENTALS PROCTORED EXAM RETAKE GUIDE COMPLETE STUDY GUIDE QUESTIONS AND ANSWERS LATEST.
The nurse should be aware of signs of physical, sexual, an... [Show More] d emotional abuse and comply with state or provincial mandatory
reporting. Signs of abuse may include:
• Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)
• Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid
• Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)
• Injuries to genitalia
• Lapsed time between the injury and the time when care is sought
• Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age,
mechanism of injury)
(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from
foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and
caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child
safety measures within the home to prevent future injury.
Educational objective:
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of
healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to
state or provincial laws.
Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the
individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and may
refuse treatment or aid out of fear of being harmed.
Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food
has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged
food (Option 4).
Educational objective:
Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while
ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened,
individually packaged food to promote adequate intake without reinforcing delusions.
Steps for indwelling urinary catheter insertion for the male client include:
• Perform hand hygiene and open sterile catheterization kit (Option 3).
• Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2).
• Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering from
catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks.
• Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now
considered contaminated and remains in this position for duration of procedure (Option 6).
• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution
using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).
• Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).
• Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter
tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra
varies in length, balloon should not be inflated until catheter is fully advanced.
Educational objective:
To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile
fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using
dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.
Allowing family to be present during resuscitative efforts and invasive procedures can help the family process
and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is
poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's
way) and another nurse should explain the treatment measures that are occurring (Option 1).
ATI FUNDAMENTALS PROCTORED EXAM
RETAKE GUIDE COMPLETE STUDY GUIDE
QUESTIONS AND ANSWERS
2
Educational objective:
During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desire.
3
Allowing family members to be present helps with coping, alleviates fear and anxiety, and facilitates the grieving process in
the case of a poor outcome.
Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed
hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for
bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should
report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider
because central line–related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis.
In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the
infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the
sample and prevent identification of the infectious organism (Option 4).
Educational objective:
When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and
remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management,
documentation) should be done after initiating treatment of the infection.
When making room assignments, it is important to remember that a client with an active or suspected infection should not
be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma
exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection
surgery (Option 3).
Educational objective:
When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is
immunocompromised in a room with a client who has an active or suspected infection. [Show Less]
