ATI RN Fundamentals Exam

Correct Answer: C. A bone scan that is scheduled for today

The correct information to include in a change-of-shift report is a bone scan that is scheduled for today. This is important for the incoming nurse to know in order to be prepared for any specific care needs or interventions related to the scheduled test. Knowing the upcoming diagnostic procedures allows the nurse to ensure proper preparations are made for the client, such as informing them of any required fasting or confirming the appointment.

Why the other options are wrong:

A. The client's input & output for the shift

Incorrect because the nurse should focus on key changes or important trends in the client’s condition during the shift. While input and output are important, they are typically documented on the client’s flow sheet and not necessarily needed for a change-of-shift report unless there are significant changes or concerns.

B. The client's BP from the previous day

Incorrect because it’s not relevant to the current shift report. The BP from the previous day may not reflect the client’s current status. The nurse should report current vital signs or any changes in the client’s condition, but past values are typically not necessary unless there's a specific concern.

D. The med routine from the med administration record

Incorrect because the medication administration record (MAR) is usually available to the incoming nurse for reference, and the report should focus on important updates or concerns. Detailed medication routines can be accessed directly from the MAR, and reporting each med in detail isn't necessary unless there are significant changes or issues (e.g., new medications, changes in dosages, or adverse reactions).

Summary:

When preparing a change-of-shift report, it is important to include current, pertinent information that will help the incoming nurse understand any changes or needs for the client’s care, such as a scheduled bone scan. Information like vital signs, planned tests, and changes in the client's condition are vital for ensuring continuity and safe care during the shift handoff.

Correct Answer: B Endotracheal suctioning

Endotracheal suctioning is performed first because it addresses airway patency, which is a priority under the ABCs of care (Airway, Breathing, Circulation). Maintaining a clear airway is critical to ensure adequate oxygenation and prevent complications such as hypoxia or respiratory distress.

Why the Other Options Are Incorrect:

A. Enteral feeding

Enteral feeding supports nutrition, but it is not an immediate priority when compared to maintaining airway patency. Nutrition can be delayed without immediate harm, whereas airway obstruction can be life-threatening.

C. Urinary catheter care

Urinary catheter care is important for infection prevention and maintaining hygiene, but it does not address a life-threatening concern. It can be postponed until after airway patency is ensured.

D. Wound irrigation

Wound irrigation is necessary for wound care and preventing infection, but it is not a priority over a compromised airway. It can safely be delayed until higher-priority needs are addressed.

Summary:

The nurse should prioritize endotracheal suctioning to address airway patency and prevent hypoxia, which aligns with the ABCs framework. While enteral feeding, urinary catheter care, and wound irrigation are important, they do not pose an immediate threat to the client's survival and can be performed afterward.​​​​​​​

Correct Answer: Cut the old ties after the new ties are secured

When changing a client’s tracheostomy ties, the nurse should ensure that the airway remains secure at all times.  Cutting the old ties only after the new ties are secured prevents accidental dislodgement of the tracheostomy tube, which could compromise the client’s airway. This action prioritizes safety during the procedure.

Why the Other Options are Incorrect:

Use a quick-release knot to secure the ties:

A quick-release knot is not recommended because it can loosen unintentionally, leading to tube dislodgement. Instead, the ties should be securely fastened using a double knot or other method that ensures stability.

Allow space for three fingers under the ties when securing:

The correct spacing is one to two fingers under the tracheostomy ties. Allowing space for three fingers would make the ties too loose, increasing the risk of dislodgement.

Extend the client's neck while securing the ties:

Extending the client’s neck could cause discomfort and misalignment, especially in clients with limited mobility or cervical spine issues. The client’s head and neck should be positioned comfortably, typically in a neutral position, during the procedure.

Summary:

The nurse should cut the old ties after the new ties are secured to maintain the client’s airway safety during the tracheostomy tie change. The other options involve practices that could lead to complications such as tube dislodgement or client discomfort. Proper technique includes ensuring ties are snug (one to two fingers’ space) and the client’s position is neutral for comfort and safety.

The following actions should be taken by the nurse:

Apply a mask on the client when they leave their room.

Wear a mask within 1 m (3 feet) of the client.

Initiate droplet precautions.

Request a prescription for an antibiotic medication.

Explanation

Apply a mask on the client when they leave their room.

The client has been diagnosed with a streptococcal infection (from the positive throat culture). Since streptococcal infections are contagious and spread through respiratory droplets, the client should wear a mask to prevent the spread of infection when leaving their room.

Wear a mask within 1 m (3 feet) of the client.

As the client has a streptococcal throat infection, droplet precautions should be followed. The nurse should wear a mask when within 3 feet of the client to prevent transmission of the bacteria via respiratory droplets.

Initiate droplet precautions.

 Streptococcal infections are spread through respiratory droplets, and droplet precautions are necessary for the protection of both staff and other patients. This includes wearing a mask when within 3 feet of the client and ensuring the client is placed in a private room if possible.

Request a prescription for an antibiotic medication.

Streptococcal infections require antibiotic therapy for treatment, as they are bacterial in nature. A prescription for antibiotics (typically penicillin or amoxicillin) should be requested to treat the infection and prevent complications such as rheumatic fever or kidney damage.

Actions that do not require immediate intervention:

Place the client in a negative airflow room.

A negative airflow room is typically used for clients with airborne infections (e.g., tuberculosis, COVID-19, measles). Streptococcal infections are spread through droplets, not airborne particles, so this is not necessary.

Apply oxygen at 2 L/min via nasal cannula.

The client's oxygen saturation is 96%, which is within the normal range. There is no indication of hypoxemia (low oxygen levels) or respiratory distress. Therefore, oxygen therapy is not needed at this time.

Summary:

The nurse should apply a mask when the client leaves the room, wear a mask when within 3 feet of the client, initiate droplet precautions, and request a prescription for an antibiotic medication. The negative airflow room and oxygen therapy are not necessary based on the current assessment and diagnosis.

Correct Actions:

Clarify the prescription for amoxicillin with the provider.

Request a prescription for an antiemetic medication.

Place the client on contact precautions.

Explanation 

Clarify the prescription for amoxicillin with the provider.

The client is allergic to penicillin, which is closely related to amoxicillin. Given the allergy, administering amoxicillin could cause an allergic reaction. The nurse should clarify the prescription and request an alternative antibiotic (such as a cephalosporin or trimethoprim-sulfamethoxazole), which is typically used to treat urinary tract infections (UTIs) in clients with penicillin allergies.

Request a prescription for an antiemetic medication.

The client is reporting ongoing mild nausea and abdominal cramping, as well as three loose stools. An antiemetic could help manage these symptoms, especially if they are related to the infection, medications, or poor dietary intake. A prescription for an antiemetic would help improve the client's comfort and ability to tolerate oral intake.

Place the client on contact precautions.

UTIs, especially those that present with fever, chills, and abdominal pain, can sometimes be caused by multi-drug-resistant organisms. Contact precautions are appropriate to prevent the potential spread of infection to other patients, particularly if there is a possibility of Clostridioides difficile (C. difficile) infection due to the client’s loose stools. Additionally, contact precautions will help protect staff from exposure to pathogens.

Explanation of Incorrect Actions:

Hold the dose of levothyroxine.

There is no indication from the provided information that levothyroxine needs to be held. The client has a history of hypothyroidism and is receiving levothyroxine as part of their maintenance treatment. Unless there is a direct issue with thyroid function or the client is unable to take the medication due to nausea/vomiting, this medication should not be withheld.

Recommend increasing the dose of metoprolol.

There is no indication that the client’s blood pressure or heart rate requires an increase in metoprolol. The client’s blood pressure and pulse are stable (e.g., BP 110/60 mm Hg and pulse rate 72/min). There is no clinical reason to suggest a change in the metoprolol dosage at this time.

Ensure the client wears a surgical mask when they are outside of their room.

The client has a urinary tract infection (UTI) and not a respiratory infection, so there is no need to require a surgical mask when the client leaves their room. The primary concern is managing the infection and addressing the gastrointestinal symptoms rather than respiratory precautions.

Summary:

The nurse should clarify the amoxicillin prescription due to the client’s penicillin allergy, request an antiemetic to manage nausea, and place the client on contact precautions due to the possibility of a contagious infection.

The Correct Answer is A: Fold the existing patch on itself and dispose of it in a childproof container.

This is the correct answer because when replacing a transdermal patch, the nurse should first remove the old patch, fold it on itself to contain any residual medication, and dispose of it in a childproof container to ensure it is safely discarded and prevent accidental exposure. The patch should not be left on after the prescribed duration, and the old one should be safely disposed of before applying a new one.

Why the other choices are incorrect:

B) Shave the client's lower leg for placement of the new patch.

This is incorrect because shaving the area is not necessary for placing a transdermal patch. In fact, shaving can irritate the skin and create microscopic cuts that might allow the medication to be absorbed too quickly. It is recommended to apply the patch to clean, dry, and hairless skin, but shaving should be avoided to prevent skin irritation.

C) Keep the existing patch on and place the new patch in a different location.

This is incorrect because the existing patch should be removed before placing a new one. Leaving the old patch on while applying a new one could result in overmedication or inconsistent dosing, and it increases the risk of side effects.

D) Discard the old patch and apply a new one in the same location.

This is incorrect because while the old patch should be discarded, it is important to apply the new patch to a different area of the skin to avoid irritation or buildup of medication in the same spot. This prevents localized skin reactions and ensures effective medication absorption.

Summary:

Fold the existing patch on itself and dispose of it in a childproof container, which ensures safe disposal and prevents accidental exposure. The other options either involve incorrect practices or unnecessary steps for patch application.

The best response is A) "He's being examined now; he's awake and talking. We'll take you to see him soon."

Option A is the best because it provides specific, factual information in a calm and reassuring manner. It acknowledges the mother's concern and provides an update about her son’s condition ("he's awake and talking"), while also offering her the next step ("We'll take you to see him soon"). This response addresses the mother’s emotional needs while maintaining professionalism.

Why the other options are incorrect:

Option B: "Don't worry, I'm sure he'll be fine; we have an excellent trauma team caring for him."

While attempting to reassure the mother, this response is overly optimistic and offers speculative information ("I'm sure he'll be fine"). It does not provide specific details about the patient's current condition and may give false hope, which can be harmful if the situation changes.

Option C: "Everything will be okay; please take a seat and I'll check on him for you."

This response is reassuring but lacks specific information about the patient's condition. It also may not be appropriate to ask the mother to wait without providing any clarity or comfort regarding her son’s status, which could escalate her anxiety.

Option D: "Your son is strong and has youth on his side; I'm sure he'll be fine."

This response is speculative and does not provide any specific, factual information about the son’s condition. It also uses language that could be interpreted as dismissive or minimizing the seriousness of the situation.

Summary:

In this situation, the nurse should respond with accurate, calm, and compassionate information. Option A best achieves this by offering specific details about the patient’s condition, reassuring the mother, and guiding her to the next step.

Correct Answer: B. Check the client's peripheral pulses and skin integrity every 15 min.

Explanation of Correct Answer:

B. Check the client's peripheral pulses and skin integrity every 15 min.

When a client is in four-point restraints, it is crucial to monitor their circulation and skin integrity frequently to prevent complications such as poor circulation, nerve damage, or pressure sores. Checking the client’s pulses and skin every 15 minutes ensures timely identification of issues and helps to prevent further harm.

Why the Other Options Are Incorrect:

A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation.

While it is important to assess the client’s condition regularly, the frequency of assessment in the case of four-point restraints should be every 15 minutes, not every hour. This ensures that any issues with circulation, injury, or discomfort are detected and addressed promptly.

C. Assist the client with passive range of motion exercises every 3 hr.

Although passive range of motion exercises are beneficial to prevent muscle atrophy and improve circulation, the more immediate priority is frequent checks of the client's pulses and skin integrity in the first few hours of restraint. Exercising the client every 3 hours does not address the more critical monitoring needs while in restraints.

D. Attach the extremity restraint straps to the bed rails using a quick-release buckle.

Restraints should never be attached to bed rails. Attaching restraint straps to the bed rails can create a risk of entrapment or injury. Restraint straps should be attached to the movable part of the bed frame, and quick-release mechanisms should be used to ensure safe removal in emergencies.

Correct Answer D. "Last bowel movement"

This is the correct answer because the nursing diagnosis specifically addresses constipation as a result of opioid use. Opioid analgesics, such as oxycodone and hydromorphone, slow gastrointestinal motility, increasing the risk of constipation. Assessing the client’s last bowel movement helps determine the severity of the constipation, guides interventions such as stool softeners or laxatives, and prevents complications like fecal impaction. Monitoring bowel habits is essential for clients on long-term opioid therapy to ensure effective bowel management and overall comfort.

Why the other choices are incorrect:

A. "Pain level"

This is incorrect because while assessing pain is always important, it is not the priority in this scenario. The focus of the nursing diagnosis is constipation, not pain management. Pain assessments should still be conducted regularly, but in this case, bowel function is the primary concern.

B. "Last opiate administration time"

This is incorrect because while opioid use is the cause of the constipation, simply knowing the last dose does not directly address the current state of bowel function. Even if the last dose was recent, constipation is typically a cumulative effect of opioid use over time. The key assessment should focus on when the client last had a bowel movement to determine the extent of constipation and need for intervention.

C. "Respiratory rate"

This is incorrect because while respiratory depression is a potential opioid side effect, it is unrelated to the specific nursing diagnosis of constipation. Respiratory assessment is crucial in opioid management, but it does not directly contribute to assessing or managing constipation.

Summary:

The priority assessment for a client with opioid-induced constipation is their last bowel movement because it directly evaluates the problem stated in the nursing diagnosis. The other options, while important in opioid management, do not specifically address constipation, making them secondary concerns in this case.