ATI MED SURG FUNDAMENTALS PROCTORED REAL EXAM AND VERIFIED CORRECT ANSWERS WITH NGN

A. Gown Rationale: The nurse should remove the gown, which is likely to have some contamination, when preparing to leave the client’s room; however, evidence-based practice indicates that another type of PPE is the priority for removal. B. Gloves Rationale: According to evidence-based practice, the nurse should remove the most contaminated item, the gloves, first. C. Face shield Rationale: The nurse should remove the face shield, which is likely to have some contamination, before leaving the client’s room; however, evidence-based practice indicates that another type of PPE is the priority for removal. D. Mask Rationale: The nurse should remove the mask, which is likely to have some contamination, at the doorway of the client’s room; however, evidence-based practice indicates that another type of PPE is the priority for removal. 88.AA nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? A. “I will wear gloves whenever I am in contact with clients.” Rationale: The AP does not need to wear gloves unless coming into direct contact with bodily fluids. B. “I will wear gloves and a gown when bathing a client who has open skin lesions.” Rationale: The AP should wear personal protective equipment when in direct contact with a client’s bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible. C. “I will wear gloves to minimize the number of times I have to wash my hands.” Rationale: The AP should change gloves and perform hand hygiene between each client and each task for the same client after coming into contact with infectious material. D. “I will wear gloves when measuring a client’s blood pressure.” Rationale: The AP does not need to wear gloves unless coming into direct contact with bodily fluids. 89.AA nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Whichof the following actions should the nurse take first? Page 41 A. Report the incident to the charge nurse. Rationale: The nurse should notify the charge nurse to follow the facility’s usual protocol for such injuries; however, another action is the priority. B. Wash the area of the puncture thoroughly with soap and water. Rationale: The greatest risk to this client is injury from any bloodborne pathogens on the needle; therefore, the first action the nurse should take is to provide immediate first aid by scrubbing the area thoroughly with soap and water. C. Complete an incident report. Rationale: The nurse should complete an incident report to assist the facility’s risk managers in investigating and devising prevention strategies as necessary; however, another action is the priority. D. Go to employee health services. Rationale: The nurse should seek evaluation and follow-up care from the facility’s employee health services department to identify his risk and begin prophylaxis as necessary; however, another action is the priority. 90.A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? A. Gloves Rationale: The greatest risk to safety is pathogen transmission. The gloves are the most contaminated item of PPE, so the nurse should remove them first. Failing to remove the most contaminated item first increases this risk. B. Gown Rationale: The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The gown is neither the most contaminated nor the least contaminated item of PPE. C. Face shield Rationale: The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The face shield is neither the most contaminated nor the least contaminated item of PPE. D. Mask Rationale: The mask is the least contaminated item of personal protective equipment; therefore, the nurse should remove it last. 91.AA nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take? Page 42 A. Provide a positive-pressure airflow room. Rationale: The nurse should place the client in a private room that has negative-pressure airflow to prevent transmission of the client’s infection. B. Wear an N95 respirator mask. Rationale: The nurse should wear an N95 respirator mask or a high-efficiency particulate air (HEPA) filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubeola, or tuberculosis. C. Allow the client to ambulate in the hall. Rationale: The nurse should limit the client’s activity outside of the room to prevent exposing others to the client’s infectious particles. D. Stand 1.8 m (6 feet) away from the client. Rationale: The nurse will have to be in closer contact with the client to give him direct care. The nurse can do so safely with the use of personal protective equipment. 92.AA nurse is caring for a client who has an infection. The nurse should use which of the following strategiesto prevent the transmission of the client’s infection? A. Changing the client’s bed linens each day Rationale: While changing linens helps maintain a clean environment, it does not stop the transmission of infection. B. Encouraging the client to consume a high-protein diet Rationale: A diet high in protein can help the client fight the infection, but it does not prevent its transmission. C. Performing hand hygiene before, during, and after direct contact with the client Rationale: The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures. D. Placing the client in a room with positive-pressure airflow Rationale: Placing the client in a positive pressure airflow room will not prevent the transmission of infection. Positive-pressure airflow keeps pathogens from entering the client’s room. This is a strategy for clients who have immune-system compromise. 93.AA nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. BUN Rationale: An elevation in BUN indicates an impairment in renal function. Page 43 B. Potassium Rationale: An elevation in potassium indicates an impairment in renal function. C. RBC count Rationale: An elevation in the RBC count indicates polycythemia. D. WBC count Rationale: An elevation in the WBC count (leukocytosis) indicates that the client’s immune system is defending him against the pathogens causing an infection. 94.AA nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Contact Rationale: The nurse should initiate contact precautions when a client has an infection that spreads through direct or indirect contact, such as major wound infections or infection with multi-drug resistant organisms such as methicillin-resistant Staphylococcus aureus. B. ?Droplet Rationale: The nurse should initiate droplet precautions when a client has an infection that spreads through droplets larger than 5 microns, such as pneumonia or streptoccocal pharyngitis. C. ?Protective Rationale: The nurse should initiate a protective environment when clients require a room with positive-pressure airflow, such as those who have undergone stem-cell transplants. D. ?Airborne Rationale: The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client. 95.AA nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? A. Properly disposing of contaminated equipment Rationale: Some clients and staff are at risk for infection from improper disposal of contaminated equipment; however, another action is the priority. B. Discarding used syringes in appropriate containers Rationale: Some clients and staff are at risk for infection from improper discarding of used syringes; Page 44 however, another action is the priority. C. Changing soiled linens daily for clients who have draining wounds Rationale: Some clients and staff are at risk for infection from soiled linens; however, another action is the priority. D. Performing hand hygiene frequently and consistently Rationale: The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care. 96.AA nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. “If you wear gloves, you do not have to wash your hands.” Rationale: Caregivers should perform hand hygiene before donning gloves and after removing them. B. “Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds.” Rationale: The staff should rub the product over all aspects of the hands and fingers until they are dry, which generally takes 20 to 30 seconds. C. “Use an alcohol rub when your hands are visibly soiled.” Rationale: When their hands are visibly soiled, caregivers should wash them with soap and running water. Then, they should use an alcohol rub to disinfect them. D. “If you don’t have an infection, your hands won’t infect others.” Rationale: Caregivers and clients can have micro-organisms on or in their body that do not harm them but can harm others. Hands can transmit them; therefore, hand hygiene is essential. 97.AA client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. ?Call the client’s provider. Rationale: The nurse will have to notify the client’s provider in case the client needs medical intervention and to follow the facility’s protocol for such incidents; however, there is another action the nurse should take first. B. Assess the client. Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions. Page 45 C. Notify the nurse manager. Rationale: The nurse will have to notify the nurse manager to follow the facility’s protocol for such incidents; however, there is another action the nurse should take first. D. Complete an incident report. Rationale: The nurse will have to complete an incident report to follow the facility’s protocol for such incidents and to give risk managers the opportunity to investigate and institute preventive measures if necessary; however, there is another action the nurse should take first. 98.When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take? A. Contact the pharmacy and confirm that the dosage is safe to administer. Rationale: A pharmacist cannot confirm that a dose that is three times the usual dose is safe to administer. B. Ask another nurse to verify that the dosage is appropriate for the client Rationale: Another nurse cannot confirm that a dose that is three times the usual dose is safe to administer. C. Contact the provider to question the dosage. Rationale: When a nurse believes there is an error in a prescription, the nurse must question the provider. D. Inform the charge nurse and administer the dose of the medication the provider prescribed. Rationale: It is inappropriate and unsafe for the nurse to administer an excessively large dose that could harm the client, no matter whom she informs. 99.AA nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. “A high concentration of carbon monoxide can cause death.” Rationale: Carbon monoxide is poisonous and prolonged exposure to it can cause brain damage, unconsciousness, and death. B. “I can detect the presence of carbon monoxide by a metallic odor.” Rationale: Carbon monoxide gas is odorless, tasteless, and colorless. C. “I should purchase a carbon monoxide detector for my home.” Rationale: The best protection against prolonged exposure to carbon monoxide in the home is a carbon monoxide detector. D. “Breathing in carbon monoxide can cause headaches and nausea.”