NGN ATI RN Fundamentals Exam 2023 A Version 1| Questions and Verified Answers|
100% Correct| A Grade
QUESTION
A nurse is caring for a client who
... [Show More] is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Ask the client to consider a direct donation.
Withhold the blood transfusion.
Request a consultation with the ethics committee.
Ask the client's family to intervene.
Answer:
Correct Answer:
Withhold the blood transfusion.
The principle of autonomy ensures that a client who is competent has the right to refuse treatment.
Incorrect Answers:
Ask the client to consider a direct donation.
A direct donation still requires a blood transfusion and does not respect the client's wishes.
Request a consultation with the ethics committee.
A client who is competent has the right to refuse treatment, regardless of the consequences. There is no need to involve the ethics committee.
Ask the client's family to intervene.
Clients who are competent have the right to consent to or refuse treatment.
QUESTION
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
Alginate
Gauze
Transparent
Hydrocolloid
Answer:
Correct Answer:
Hydrocolloid
Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.
Incorrect Answers:
Alginate
Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage.
Gauze
Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed.
Transparent
Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing.
QUESTION
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply)
Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
Limit each visitor to 2-hr increments.
Wear a surgical mask when providing client care.
Use antimicrobial sanitizer for hand hygiene.
Answer:
Correct Answers:
Place the client in a room with negative-pressure airflow.
The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions.
Wear gloves when assisting the client with oral care.
The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth.
Use antimicrobial sanitizer for hand hygiene.
The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.
Incorrect Answers:
Limit each visitor to 2-hr increments.
The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room.
Wear a surgical mask when providing client care.
The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.
QUESTION
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?
Document the provider's statement in the medical record.
Complete an incident report.
Consult the facility's risk manager.
Notify the nursing manager.
Answer:
Correct Answer:
Notify the nursing manager.
The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.
Incorrect Answers:
Document the provider's statement in the medical record.
The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority.
Complete an incident report.
The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority.
Consult the facility's risk manager.
The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority.
QUESTION
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?
Suction the client's airway.
Instruct the client to perform incentive spirometry every hour.
Humidify the client's supplemental oxygen.
Assist the client to an upright position.
Answer:
Correct Answer:
Assist the client to an upright position.
According to evidence-based practice the nurse should assist the client to an upright position. This assists with chest expansion and increases the effectiveness of the existing supplemental oxygen. The nurse should elevate the head of the client's bed to the semi-Fowler's or high-Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.
Incorrect Answers:
Suction the client's airway.
The use of suction to remove pulmonary secretions can help to ease the client's breathing. However, evidence-based practice indicates that there is another intervention that the nurse should implement first.
Instruct the client to perform incentive spirometry every hour.
Humidify the client's [Show Less]