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ATI IMP FOR CNF QUESTIONS WITH CORRECT ANSWERS A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. administer aspirin b. tilt the child's head and apply the pressure c. have the child lie down and rest d. apply continuous pressure to the lower part of the child's nose CORRECT ANSWER d. apply continuous pressure to the lower part of the child's nose with the child sitting up and breathing through the mouth, apply continuous pressure with thumb n forefinger to the soft lower area of the nose for 10 min. most bleeding from the nose stops within this period incorrect Aspirin can increase bleeding from the site due to its antithrombotic action tilting head back allows blood to flow down the back of throat, causing nausea lying down increases risk of aspirating blood A nurse is caring for a client who is 48 hr. postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A. Blood loss B. NPO status after surgery C. Nasogastric tube suctioning D. impaired peristalsis of the intestine CORRECT ANSWER Correct answer: (D) Impaired peristalsis of the intestines. Normal bowel function is delayed for up to several days following bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain n abdominal distention. plan to help the client ambulate to promote peristalsis. Incorrect Answers: A. Blood loss can cause shock but does not contribute to the findings demonstrated by this client. B. NPO status after surgery can cause dehydration but does not contribute to the findings demonstrated by this client. C. Nasogastric tube suctioning keeps the stomach and intestines decompressed and can help prevent the findings demonstrated by this client. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed. B. Tie the restraint with a quick-release knot. C. Allow a fingerbreadth between the restraint and the client's chest. D. Place the restraint under the client's clothing. CORRECT ANSWER Correct answer: (B) Tie the restraint with a quick-release knot. The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints. Incorrect Answers: A. should not fasten the ties on the restraint to the side rails. If the side rails are lowered, client could be injured. C. allow two fingerbreadths between restraint in the client's chest. D. apply the restraint over the client's clothing. A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration CORRECT ANSWER Correct answer: (A) Drop the eye medication into the lower conjunctival sac The nurse should drop eye medication in lower conjunctival sac to avoid placing drops on cornea n causing damage. Incorrect Answers: B. should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running down the duct or out of the eye. C. should hold eyedropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea of eye from injury by preventing tip of dropper touching eye. D. instruct the client to close the eyes gently when applying ointment or liquid to distribute medication and to avoid expelling the medication or injuring the eye. A nurse is performing a comprehensive physical assessment of a client. nurse should use inspection to assess which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait CORRECT ANSWER Correct answer: (D) Gait. Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing any unusual findings. Incorrect Answers: A. Evaluating liver size requires palpation. B. Evaluating pedal edema requires palpation. C. Evaluating skin texture requires palpation. vvIMP= A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2 ft behind the client during ambulation CORRECT ANSWER Correct answer: (A) Use a gait belt during ambulation. use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall. Incorrect Answers: B. ensure client is wearing non-skid shoes or slippers when ambulating to decrease risk of fall from slipping C. encourage client to dangle legs on edge of bed for 60 seconds before attempting to ambulate to decrease the risk of a fall due to orthostatic hypotension. D. walk beside the client to provide physical support while ambulating and decrease the risk of a fall. A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients. B. Clients who are age 65 or older are reluctant to report pain. C. Clients who are age 65 or older should not receive opioid narcotics. D. Clients who are age 65 or older experience a shorter duration of action with medications than young adult clients. CORRECT ANSWER Correct answer: (B) Clients who are age 65 or older are reluctant to report pain. instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected. Incorrect Answers: A. Clients age 65 and older do not experience a decrease in pain perception. C. Clients age 65 and older can receive opioid narcotics for pain relief. However, these clients metabolize medications slowly n might require lower doses than younger adults. D. Renal and liver function declines with age. Therefore, medications have a longer duration of action in clients who are age 65 and older. frequently monitor these clients for adverse effects n may need to administer a lower dosage of the medication at longer intervals compared to young adult clients. A nurse is providing teaching to a client who has a new prescription for alprazolam. Which of the following items is a priority for teaching? A. "This medication can affect your ability to drive or handle mechanical equipment." B. "You should avoid drinking beverages that contain caffeine with this medication." C. "You should avoid taking antacids within 2 hours of this medication." D. "This medication should be taken with or shortly after meals." Flag question for later CORRECT ANSWER Correct answer: (A) "This medication can affect your ability to drive or handle mechanical equipment." apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Handling mechanical equipment or driving creates a safety risk for the client who takes alprazolam. Incorrect Answers: B. While consumption of caffeine can decrease the desired action of the medication, it is not the priority for this teaching. C. While antacids can delay absorption, this is not the priority for this teaching. D. While taking this medication with or shortly after meals can reduce gastrointestinal discomfort, it is not the priority for this teaching. A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L CORRECT ANSWER Correct answer: (B) Potassium 3.0 mEq/L. potassium level is below the expected reference range, indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration. A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? Lower medial quadrant of the buttock near the coccyx Side hip between the iliac crest and anterior iliac spine Tissue of the posterior upper arm Lower inner thigh 4 finger-widths above the patella CORRECT ANSWER Correct answer: (B) Side hip between the iliac crest and anterior iliac spine. side hip between iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is appropriate site. This site is preferred for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (e.g. right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Incorrect Answers: A. To administer an intramuscular medication using the dorsogluteal site, the nurse should select the upper lateral quadrant of the buttock. However, this site can increase the risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is an increased risk of piercing the sciatic nerve. C. select the outer posterior tissue of the upper arm for subcutaneous injection. For intramuscular injections that are 1 mL, select deltoid muscle by placing 4 fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is three finger widths below the acromion process, or about 5 cm (2 in). D. To administer intramuscular medication using the vastus lateralis site, select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place a hand below the greater trochanter and the other hand just above the knee to locate the middle portion of the muscle for the injection site. A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?