RN ATI Fundamentals 2019 Exam w ith NGN Updated 2024 wit h All Ques tions from Actual Past Exam and 100% Correct Answers Question 1: A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia? A. Shakiness B. Cool skin C. Thirst D. Confusion Show correct answer and explanation Explanation Choice A reason: Shakiness is incorr ect because it may be a symptom of hypoglycaemia (low blood sugar) rather than hyperglycaemia. Choice B reason: Cool skin is incorrect because it is not a typical symptom of hyperglycaemia; in fact, individuals with hyperglycaemia may experience warm, dry skin due to dehydration. Choice C reason: Thirst is the correct indication because it is a common symptom of hyperglycaemia (high blood sugar) in clients with diabetes mellitus. When blood sugar levels are elevated, the kidneys try to excrete the excess sugar through the urine, which can lead to i ncreased urination and subsequently, dehydration. This dehydration can result in increased thirst as the body attempts to compensate for the fluid loss. Choice D reason: Confusion is not the correct answer because it is a potential symptom of severe hyperglycaemia, especially in more advanced cases, but it's not as specific as increased thirst. Question 2: A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A. Document the fluid infusion in the client's chart. B. Complete an incident report. C. Obtain the client's vital signs. D. Report the incident to the unit manager. Show correct answer and explanation Explanation Choice A reason: Documenting the fluid infusion in the client's chart: While documenting the fluid infusion is important, assessing the client's vital signs should take priority to ensure their immediate safety and well -being. Choice B reason: Completing an incident report is incorrect Completing an incident report is a necessary step to document the error and initiate appropriate follow -up actions, but it should come after assessing the client's condition. Choice C reason Obtaining the client's vital signs is the correct answer. The correct first action for the nurse to take in this situation is to obtain the client's vital signs. Administering an ex cessive amount of IV fluid could potentially have adverse effects on the client's cardiovascular system, including fluid overload, electrolyte imbalances, and changes in blood pressure. Monitoring the client's vital signs will help assess their current con dition and any potential complications resulting from the excess fluid administration. Choice D reason Reporting the incident to the unit manager is incorrect. Reporting the incident to the unit manager is important for organizational awareness and account ability, but the nurse's first responsibility is to assess the client's vital signs and address any potential complications. Question 3: A nurse is documenting client care. Which of the following abbreviations should the nurse use? A. "OJ" for orange juice B. "SS" for sliding scale C. "SQ" for subcutaneous D. "BRP" for bathroom privileges Show correct answer and explanation Explanation Choice A reason: "OJ" for orange juice is not recommended. While it might seem straightforward, "OJ" could be confused with "oj" or other abbreviations, leading to potential confusion. It's better to write out "orange juice." Choice B reason: "SS" for sliding scale is not recommended" could be misinterpreted or confused with other meanings. It's safer to write out "sliding scale." Choice C reason: "SQ" for subcutaneous is appropriate This is an accepted abbreviation for the subcutaneous route of medication administration. Choice D reason: "BRP" for bathroom privileges is not recommended: "BRP" is a common abbreviation that stands for "bathroom privileges" and is widely understood in healthcare settings. Question 4: A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client? A. Protective B. Droplet C. Airborne D. Contact Show correct answer and explanation Explanation Choice A reason: Protective precautions are not necessary because they (also known as reverse isolation) are used for immunocompromised clients to protect them from potential pathogens carried by healthcare workers or visitors. Choice B reason: Droplet precautions are not necessary because they are used for infections spread through larger respiratory droplets, like influenza or pertussis. Choice C reason: Airborne precautions should be implemented by the nurse. Tuberculosis (TB) is primarily transmitted through the airborne route, as the bacteria that cause TB can be suspended in the air as tiny particles (droplet nuclei) when an infected person coughs, sne ezes, speaks, or sings. These particles can be inhaled by others, leading to the potential transmission of the disease. Choice D reason: Contact precautions are not necessary because they are used for infections that
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