ATI PN 112 Final Exam 12/25
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Free ATI PN 112 Final Exam 12/25 Questions
A staff nurse suspects that a newly licensed nurse is chemically impaired. Which of the following actions should the staff nurse take?
- Notify the charge nurse of the situation.
- Examine unit narcotic records.
- Confront the newly licensed nurse regarding her behavior.
- Arrange transportation home for the newly licensed nurse.
Explanation
Explanation
When a nurse suspects chemical impairment in a colleague, the appropriate initial action is to notify the charge nurse or supervisor. This ensures the concern is handled through proper channels according to facility policy, protects client safety, and allows for timely assessment and intervention. Direct confrontation, independent investigation of narcotic records, or arranging transportation are not appropriate first actions and may compromise safety or policy compliance.Correct Answer Is:
A. Notify the charge nurse of the situation.A nurse is reinforcing teaching with a middle-age client who is at high risk for osteoporosis and is taking oral calcium gluconate. Which of the following instructions should the nurse include in the teaching?
- Take with zinc-rich foods.
- Take the calcium supplement on an empty stomach.
- Take vitamin D supplements.
- Take the calcium supplement with whole grain cereal at breakfast.
Explanation
Explanation
Vitamin D is essential for calcium absorption in the gastrointestinal tract and plays a key role in maintaining bone health. Clients at high risk for osteoporosis benefit from adequate vitamin D intake to enhance the effectiveness of calcium supplementation. Taking calcium with foods high in fiber, such as whole grains, can decrease absorption, and calcium does not need to be taken on an empty stomach.Correct Answer Is:
C. Take vitamin D supplements.A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment? (Select all that apply.)
- Transporting a cerebrospinal fluid specimen to the laboratory
- Suctioning secretions from a child’s newly placed tracheostomy tube
- Giving personal care to an infant who is HIV-positive
- Withdrawing cord blood from a neonate
- Providing a newborn’s first bath
Explanation
Explanation
Explanation of Correct Answers:B. Suctioning secretions from a child’s newly placed tracheostomy tube
Suctioning a tracheostomy places the nurse at high risk for exposure to respiratory secretions that can splash or aerosolize. Protective eye equipment is required to prevent contact of secretions with the mucous membranes of the eyes, which is a known route of transmission for infectious organisms.
D. Withdrawing cord blood from a neonate
Withdrawing cord blood involves direct handling of blood and carries a risk of splashing or spraying, especially if the cord is under pressure. Protective eye equipment helps prevent exposure of the eyes to bloodborne pathogens, making it an essential component of standard precautions during this procedure.
Correct Answer Is:
B. Suctioning secretions from a child’s newly placed tracheostomy tubeD. Withdrawing cord blood from a neonate
A nurse is in a provider’s office collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- Random blood glucose 126 mg/dL
- History of poor wound healing
- Report of decreased urinary output
- Clammy skin
Explanation
Explanation
Chronic hyperglycemia impairs circulation, immune function, and tissue repair, leading to delayed or poor wound healing. Persistently elevated blood glucose levels interfere with leukocyte function and collagen formation, increasing the risk for infections and slow healing of cuts or ulcers. A random glucose of 126 mg/dL is not diagnostic of hyperglycemia, decreased urine output suggests dehydration or hypoglycemia, and clammy skin is more commonly associated with hypoglycemia.Correct Answer Is:
B. History of poor wound healingA nurse is teaching a class to new staff members about the importance of a positive work environment. Which of the following could be used as an example of professional comportment?
- Completing all care tasks before the end of the shift
- Postponing documentation in the medical record
- Staff members socializing at the nurse’s station
- Collaboration among staff to complete tasks
Explanation
Explanation
Professional comportment refers to behaviors that promote respect, teamwork, and high-quality client care. Collaboration among staff demonstrates professionalism by fostering effective communication, shared responsibility, and mutual support. This approach enhances efficiency, reduces errors, and contributes to a positive work environment. Socializing at the nurse’s station and delaying documentation are unprofessional behaviors, and simply completing tasks does not fully reflect professional interaction.Correct Answer Is:
D. Collaboration among staff to complete tasksThe nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
- Empty the collection container every shift.
- Maintain the drainage container below the level of the client’s chest.
- Add tap water as needed to the suction control chamber.
- Clamp the chest tubes if it becomes disconnected.
Explanation
Explanation
The chest tube drainage system must be kept below the level of the client’s chest to promote gravity drainage and prevent backflow of air or fluid into the pleural space. This positioning helps maintain negative pressure within the system, which is essential for lung re-expansion in a client with pneumothorax. The container is not emptied routinely, only sterile water is used in chambers, and chest tubes should not be clamped if disconnected.Correct Answer Is:
B. Maintain the drainage container below the level of the client’s chest.Vital Signs
Respiratory rate 90/min
Heart rate 162/min
Blood pressure 70/45 mm Hg
Temperature 37.5° C (99.5° F)
Oxygen saturation 92%
Nurses' Notes
Newborn is experiencing tachypnea, grunting, nasal flaring and
substernal retractions. Acrocyanosis noted on extremities bilaterally.
Diagnostic Results
Blood glucose level 40 mg/dL (30-60 mg/dL)
Bilirubin level 4 mg/dL (1.0-12.0 mg/dL)
pH 7.30 (7.32-7.45)
PaO2 60 mm Hg (60-80 mmHg)
PaCO2 32 mm Hg (40-50 mm Hg)
Bicarbonate (HCO3) 17 mEq/L (16-24 mEq/L)
A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hours old.
Which condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress?
-
Condition: Hyperbilirubinemia
Actions: Initiate phototherapy as prescribed; Bottle-feed 30 mL of formula
Parameters to monitor: Bilirubin level; Signs of overstimulation -
Condition: Hypoglycemia
Actions: Bottle-feed 30 mL of formula; Obtain a urine toxicology screen
Parameters to monitor: Blood glucose level; Urine output -
Condition: Respiratory distress syndrome
Actions: Administer oxygen per facility protocol; Assist with administration of surfactant
Parameters to monitor: Oxygen saturation; Arterial blood gases -
Condition: Neonatal abstinence syndrome
Actions: Obtain a urine toxicology screen; Initiate phototherapy as prescribed
Parameters to monitor: Signs of overstimulation; Blood glucose level
Explanation
Explanation
This newborn demonstrates classic signs of respiratory distress, including tachypnea, grunting, nasal flaring, retractions, hypoxemia, and abnormal arterial blood gases with respiratory alkalosis and metabolic acidosis. Respiratory distress syndrome can occur in late-preterm infants due to insufficient surfactant. Priority nursing actions include providing supplemental oxygen and assisting with surfactant therapy to improve alveolar expansion. Monitoring oxygen saturation and arterial blood gases allows evaluation of respiratory status and response to treatment.Correct Answer Is:
C. Condition: Respiratory distress syndrome; Actions: Administer oxygen per facility protocol and assist with administration of surfactant; Parameters to monitor: Oxygen saturation and arterial blood gasesA nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)
- Edema
- Symmetrical joint pain
- Tophi
- Erythema
- Tight skin
Explanation
Explanation
Explanation of Correct Answers:A. Edema
During an acute gout exacerbation, inflammation caused by uric acid crystal deposition leads to significant swelling of the affected joint. Increased vascular permeability allows fluid to accumulate in the tissues, resulting in noticeable edema. This swelling contributes to pain, reduced range of motion, and joint stiffness commonly seen during gout flares.
C. Tophi
Tophi are deposits of monosodium urate crystals that form in individuals with chronic or recurrent gout. While more common in long-standing disease, they may still be present during an acute exacerbation. Tophi often appear as firm nodules around joints, ears, or soft tissues and indicate ongoing hyperuricemia requiring medical management.
D. Erythema
Acute gout causes intense inflammation, leading to redness of the skin over the affected joint. The erythema results from increased blood flow to the inflamed area and is often accompanied by warmth and tenderness. The skin may appear shiny and inflamed, sometimes resembling an infectious process.
E. Tight skin
The rapid onset of swelling and inflammation during a gout flare can cause the skin over the affected joint to feel tight and stretched. This tightness occurs due to edema and increased pressure within the joint and surrounding tissues, contributing to discomfort and limited mobility during an acute attack.
Correct Answer Is:
A. EdemaC. Tophi
D. Erythema
E. Tight skin
A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator mask when caring for a client who has which of the following disorders?
- Mycoplasmal pneumonia
- Scabies
- Scarlet fever
- Tuberculosis
Explanation
Explanation
Tuberculosis is an airborne infection caused by Mycobacterium tuberculosis and is transmitted through inhalation of airborne droplet nuclei. An N95 respirator is required to protect healthcare workers from inhaling infectious particles. Mycoplasmal pneumonia and scarlet fever require droplet precautions, and scabies requires contact precautions, none of which require an N95 respirator.Correct Answer Is:
D. TuberculosisA nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- Dyspnea
- Frothy sputum
- Peripheral edema
- Orthopnea
Explanation
Explanation
Right-sided heart failure leads to impaired pumping of blood into the pulmonary circulation, causing blood to back up into the systemic venous system. This results in fluid accumulation in dependent areas of the body, most commonly presenting as peripheral edema in the lower extremities. Other common findings may include jugular venous distention, hepatomegaly, ascites, and weight gain due to fluid retention.Correct Answer Is:
C. Peripheral edemaHow to Order
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