which of the following will probably result in a break in sterile technique for respiratory isolation
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

2. Why is a precise amount of oxygen necessary for a patient with COPD to prevent which complication?

Correct answer: D

Rationale: In patients with COPD, the respiratory drive is often stimulated by low oxygen levels. Administering too much oxygen can inhibit this hypoxic drive, leading to respiratory depression and potential respiratory failure. Therefore, it is crucial to carefully regulate the oxygen therapy to prevent the inhibition of the respiratory hypoxic stimulus in COPD patients.

3. Which of the following is not a cause of tachycardia?

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

4. When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?

Correct answer: B

Rationale: In situations involving potential organ donation, the nurse's role is to provide support, listen to the family's concerns, and answer their questions truthfully. By doing so, the nurse can help facilitate an informed and respectful decision-making process for the grieving family.

5. When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?

Correct answer: B

Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.

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