Review ATI Fundamental Exams (2024)

Placing clean linen that touched the floor in the soiled linen bag prevents cross-contamination and maintains cleanliness. It adheres to infection control standards by ensuring that only soiled items are disposed of appropriately.

Holding the soiled linen against her body while carrying it to the linen bag risks transferring pathogens to the caregiver's clothing and skin, compromising personal hygiene and promoting contamination.

Shaking the soiled linen to remove any toilet paper remnants is ineffective and hazardous. It disperses potentially infectious particles, increasing the risk of contamination and compromising infection control efforts.

This statement is incorrect. Hospice care focuses on providing comfort and quality of life rather than seeking a cure for the client's illness. The primary goal is to alleviate symptoms and support the client and their family through the end-of-life process.

This statement contains a typographical error ("dyes" instead of "days") and does not accurately reflect the purpose of hospice care. Hospice teams assist with managing symptoms, addressing emotional and spiritual needs, and providing support to the client and their family during the end-of-life journey.

This statement correctly captures the essence of hospice care. Hospice services are available to patients who have a terminal illness and a life expectancy of six months or less, regardless of their specific diagnosis or prognosis. The focus is on providing compassionate care and support to enhance the quality of life during the final stages of illness.

Contact:Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.

Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.

Protective:Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.

Report by patient that something has given way:A patient reporting that something has given way is a significant indicator of potential wound dehiscence. Wound dehiscence refers to the partial or complete separation of the layers of a surgical wound, which can occur due to various factors such as poor wound healing, infection, or increased intra-abdominal pressure. Patients may describe a sensation of "something giving way" or "popping" if the wound starts to separate.

Drainage that is odorous and purulent:
Odorous and purulent drainage from an incision site may indicate an infection, which can contribute to wound dehiscence. However, this finding alone may not necessarily indicate immediate wound dehiscence.

Protrusion of visceral organs through a wound opening:Protrusion of visceral organs through a wound opening is a severe complication known as evisceration, which is the most advanced stage of wound dehiscence. While this finding is indicative of a significant wound complication, it typically occurs after the initial separation of wound layers. Therefore, it is not an early sign that would alert the nurse to potential wound dehiscence

An increase in RBCs:An increase in red blood cells (RBCs), known as erythrocytosis, is not typically associated with an infection. Erythrocytosis may occur in conditions such as polycythemia vera or chronic hypoxemia but is not a typical marker of infection.

Bradycardia:Bradycardia, a heart rate slower than the normal range, is not typically associated with infections. Infections often cause tachycardia (an increased heart rate) as part of the body's systemic inflammatory response.

An increase in platelets:An increase in platelets, known as thrombocytosis, is not typically associated with infections. Thrombocytosis can occur in response to various factors, including inflammation, but it is not a specific marker of infection in diabetic clients with foot pain.

You should advance the cane 12 to 14 inches before taking a step:Advancing the cane 12 to 14 inches is too far. The cane should be advanced approximately 6 to 10 inches to maintain balance and support.

The cane’s height should be the same as the distance from the floor to the crest of your hip bone:
The correct height for a cane is when the handle is at the level of the wrist when the user is standing with the arm hanging naturally at their side. This typically corresponds to the distance from the floor to the greater trochanter (hip bone). This ensures the cane provides the right amount of support and reduces the risk of strain or imbalance.

You should hold the cane in your weak hand when ambulating:The cane should be held in the stronger hand, not the weak hand. This allows the cane to provide support to the weaker side of the body and helps to balance the weight distribution more effectively.

"I’ll sleep better if I take a sleeping pill at night."Taking a sleeping pill can relax the muscles of the throat, which might worsen sleep apnea by increasing the likelihood of airway obstruction during sleep.

"If I could lose about 50 pounds, I might stop having so many apneic episodes."
Weight loss is a key factor in reducing the frequency and severity of obstructive sleep apnea. Excess weight, particularly around the neck, can increase the risk of airway obstruction during sleep.

"I’ll get a humidifier to run at my bedside at night."While a humidifier can make the air more comfortable to breathe, it does not directly reduce the number of apneic episodes. It might help with symptoms like dry mouth or nasal congestion but is not a primary treatment for obstructive sleep apnea.

Diet cola:Cola contains caffeine, even in diet versions, which can contribute to sleep disturbances. Therefore, it is not suitable for decreasing caffeine intake.

Brewed iced tea:
Brewed iced tea contains caffeine, which can interfere with sleep. It is not a suitable option for someone trying to reduce caffeine consumption.

Lemon-lime soda:Lemon-lime sodas typically do not contain caffeine, making them a better choice for someone looking to reduce their caffeine intake and improve sleep.

Decreased heart rate:The body's natural response to hypovolemia includes an increase in heart rate, known as tachycardia, as the heart attempts to pump the remaining blood more efficiently to vital organs. This compensatory mechanism aims to maintain cardiac output despite the decreased blood volume.

Dyspnea:
Dyspnea, or difficulty breathing, can occur in many medical conditions, including heart failure and respiratory issues. While it can be seen in severe cases of hypovolemia, particularly if the condition leads to shock and subsequent multi-organ failure, it is not a primary or specific sign of hypovolemia.

Weak pulse:A weak pulse is a primary and direct manifestation of hypovolemia. Due to the reduced volume of circulating blood, the heart has less blood to pump with each contraction, leading to a weaker pulse. This symptom indicates a decreased perfusion pressure, which is characteristic of hypovolemia. The body's compensatory mechanisms include vasoconstriction and an increased heart rate, but these measures often result in a pulse that is rapid but weak.

Stand on the left side of the bed:While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.

Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.

Use the non-dominant hand to insert the catheter:The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.