RN Fundamentals Exam 3

ATI RN Fundamentals Exam 3

Total Questions : 68

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Question 1: View

The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?

Explanation

A. This is crucial because informed consent is not just about signing a document; it's about ensuring that the client fully understands the procedure, including the risks, benefits, and alternatives. The physician can then re-evaluate the client's comprehension and provide further clarification if necessary. It is the responsibility of the healthcare team to ensure that the client is making an informed decision.
B. Explaining the procedure in simple terms may be part of the nurse's role, but it is essential that the physician is aware of any gaps in the client's understanding to address them appropriately.
C. Cancelling the surgery is not the immediate best action without first attempting to resolve the misunderstanding.
D. Witnessing the client's signature may be part of the nurse's role, but it is essential that the physician is aware of any gaps in the client's understanding to address them appropriately.


Question 2: View

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

Explanation

C. Respect for the deceased person's cultural and religious beliefs is crucial. Care should be provided in a manner that aligns with their customs and traditions. This may involve specific rituals, prayers, or practices depending on the individual's cultural or religious background.
A. While completing documentation on the death certificate is important for legal and administrative purposes, it is not the priority during post-mortem care.
B. While it's essential to handle the deceased person's belongings with care and ensure they are returned to the family, this task can typically wait until after the immediate post-mortem care has been provided. It's not the priority during the initial stages of post-mortem care.
D. This task is important, but it should be carried out after the completion of post-mortem care. Once the deceased person has been respectfully prepared, the next step is to transfer them to the morgue or the designated location.


Question 3: View

A drug that is classified as being a "hypnotic" means that it will:

Explanation

A. Hypnotic drugs are primarily used to induce sleep or promote sleepiness. They act on the central nervous system to depress its activity, leading to sedation and ultimately sleep. These drugs are commonly prescribed to treat insomnia or to induce anesthesia for surgical procedures.
B. While some hypnotic drugs can cause a stupor-like state, inducing a state of reduced consciousness or awareness, this is not the primary function of all hypnotic medications. Stupor typically refers to a state of extreme lethargy or mental dullness, which may be induced by certain drugs but is not inherent to the classification of hypnotics.
C. Hypnotic drugs are not primarily intended to affect pain. While some hypnotic medications may have analgesic properties, their primary function is to induce sleep or sedation rather than directly targeting pain relief. Pain relief is typically achieved through the use of analgesic medications such as opioids, NSAIDs, or other pain relievers.
D. Hypnotic drugs do not mimic the state of hypnosis induced by techniques such as hypnotherapy. While both hypnosis and hypnotic drugs can alter consciousness, they work through different mechanisms


Question 4: View

The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

Explanation

A. Changing the client's arm position, such as raising or lowering it, could potentially improve flow by altering the gravitational pull on the IV solution. For example, raising the arm could increase flow due to increased pressure, while lowering it could decrease flow. However, this approach may not always be effective and should be done cautiously to avoid discomfort or compromising the integrity of the IV site.
B. Using an infusion pump can help regulate the flow rate of the IV solution more accurately compared to gravity alone. However, if the IV is running slowly due to factors unrelated to the infusion rate setting, such as a partial blockage or resistance in the IV line, using an infusion pump may not necessarily improve the flow rate.
C. Lowering the height of the IV pole can increase the gravitational force acting on the IV solution, potentially improving flow. This adjustment can help overcome minor obstructions in the IV line and facilitate better flow. However, it should be done cautiously to avoid excessive pressure on the IV site or causing discomfort to the client.
D. Opening the clamp fully for an extended period is not a recommended approach. It could lead to rapid infusion or an excessive flow rate, increasing the risk of complications such as fluid overload or vein irritation. Additionally, this action does not address the underlying reason for the slow flow rate and may not effectively resolve the issue.


Question 5: View

A client requires a medication immediately. Which abbreviation would be written in the physician's order for this medication?

Explanation

A. "STAT" stands for "immediately" or "at once" in medical terminology. When a medication order is marked as STAT, it means that the medication should be administered as soon as possible, without delay. This abbreviation is used for urgent situations where the medication needs to be given promptly.
B. "PRN" stands for "pro re nata," which translates to "as needed" in Latin. When a medication order is marked as PRN, it means that the medication should be administered as required based on the patient's needs or symptoms. The timing of administration is not fixed but depends on specific conditions or situations, such as pain or nausea.
C. "TID" stands for "ter in die," which translates to "three times a day" in Latin. When a medication order is marked as TID, it means that the medication should be administered three times daily, at regular intervals throughout the day.
D. "QID" stands for "quater in die," which translates to "four times a day" in Latin. When a medication order is marked as QID, it means that the medication should be administered four times daily, at regular intervals throughout the day.


Question 6: View

A client will require IV antibiotics for several weeks. Which venous access device would be most appropriate to be used for this client?

Explanation

B. A PICC line is a long, flexible catheter inserted into a peripheral vein, typically in the upper arm, and advanced until the tip lies in the superior vena cava or the cavoatrial junction. PICC lines are suitable for long-term venous access and are often used for administering medications, including antibiotics, over several weeks or months. They offer stable and reliable access, reducing the need for frequent venipunctures.

A. Butterfly needles are typically used for short-term venous access, such as for blood draws or administering medications that do not require long-term therapy. They are not suitable for prolonged use or for administering medications over several weeks, as they are not designed for secure and stable access over an extended period.
C. A peripheral IV-lock, also known as a saline lock or heplock, is a short catheter inserted into a peripheral vein and then capped off for intermittent use. While peripheral IV-locks are suitable for short-term venous access, they are not ideal for prolonged therapy lasting several weeks. Additionally, they may not provide the necessary stability and reliability for administering IV antibiotics over an extended period.
D. A small gauge peripheral angiocath refers to a short catheter inserted into a peripheral vein for intravenous access. While a larger gauge catheter, such as a 16-gauge, may allow for faster infusion rates and is suitable for certain situations requiring rapid fluid administration, it may not be the most appropriate choice for long-term IV antibiotic therapy. The choice of gauge depends on factors such as the client's vein size, the viscosity of the medication, and the duration of therapy.


Question 7: View

A client requires an IV antibiotic piggyback. The nurse understands that the primary IV solution with gravity flow tubing needs to be hung:

Explanation

A. Positioning the primary IV solution bag higher than the piggyback medication bag creates a pressure gradient, allowing the primary solution to infuse first. Once the primary solution has finished, the secondary piggyback medication automatically starts infusing. This setup ensures that the primary solution is fully infused before the piggyback medication begins.
B. Placing the primary IV solution bag lower than the piggyback medication bag is not the standard practice. This setup would create a pressure gradient that could result in the piggyback medication infusing before the primary solution, which is not desirable. It could lead to incomplete infusion of the primary solution and compromise the effectiveness of the treatment.
C. Positioning the primary IV solution bag at the same height as the piggyback bag does not create a pressure gradient for sequential infusion. As a result, both solutions would flow at the same rate, and it would be challenging to control the order of infusion. This setup is not appropriate for administering IV antibiotics via piggyback because it does not ensure the proper sequence of infusion.
D. The height of the IV solution relative to the insertion site is essential for proper infusion and preventing complications such as infiltration or phlebitis. Ideally, the IV solution should be hung at a height that allows for a gentle flow of fluid into the vein without causing excessive pressure or backflow. Placing the IV solution lower than the insertion site helps facilitate gravity-assisted flow into the vein.


Question 8: View

The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

Explanation

A. These are indicative of inflammation within the vein, which is characteristic of phlebitis. Warmth is a common sign of inflammation, and the palpable cord suggests that the vein may be hardened or cord- like due to inflammation and irritation.
B. While this could indicate some form of vascular injury or extravasation, it is not a typical presentation of phlebitis. Phlebitis involves inflammation of the vein, which may cause redness, warmth, and tenderness along the course of the vein, but it typically does not manifest as a raised ecchymotic (bruised) area.
C. Swelling occurs due to inflammation within the vein, and tenderness is often present as a result of the irritation and inflammation. These symptoms are commonly observed in cases of phlebitis but are not specific.
D. These are not typical signs of phlebitis. Blanching (turning white) and coolness of the skin may suggest reduced blood flow to the area, which could occur in cases of ischemia or thrombosis but are not characteristic of phlebitis.


Question 9: View

A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?

Explanation

B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.

D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.


Question 10: View

A nurse caring for a client who has a peripheral intravenous saline lock understands that its purpose is to:

Explanation

C. This allows healthcare providers to quickly administer treatments without the need for repeated venipuncture, which can be beneficial in various medical situations where time and vein preservation are critical.
A. Peripheral intravenous saline locks are not typically used to accommodate highly irritating or hyperosmolar solutions. Saline locks are used to maintain venous access without continuous infusion, and they are generally used with isotonic solutions to prevent complications such as phlebitis or infiltration.
B. The access is not very reliable when used for drawing samples repeatedly.
D. While peripheral intravenous saline locks can be used for intermittent administration of IV antibiotics or other medications, they are not typically used for prolonged IV antibiotic administration.


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