ATI Comprehensive Online Practice
2024 A
A nurse is appearing tracheostomy care for a client who is postoperative following a
laryngectomy. Which of the subsequent actions must the nurse take while suctioning the
client's airway?
A. Withdraw the catheter if the client begins coughing
B. Apply suction for 10 seconds
C. Advance the catheter 2 cm (0.8 in) after resistance is met
D. Use clinical asepsis when appearing the process - ANSCORRECT: Apply suction for 10
seconds
Rationale: The nurse ought to apply suction for most effective 5 to fifteen seconds to reduce
oxygen loss.
Rationale A: Suctioning can provoke the cough reflex because it opens the airway in addition
and lets in for more effective elimination of mucus.
Rationale C: Once resistance is met, the nurse must withdraw the catheter 1 to two cm
(zero.4 in to 0.Eight in) to save you negative bronchial tissues.
Rationale D: The nurse ought to use surgical asepsis whilst suctioning a newly created
tracheostomy to lessen the hazard for contamination.
A nurse is teaching about overall parenteral vitamins (TPN) and IV lipid emulsions with a
customer who has an extensive burn injury. Which of the following information need to the
nurse consist of?
A. "This sort of vitamins is greater effective than eating by mouth.:
B. "You will get hold of fingersticks for blood glucose testing."
C. "TPN is a way to provide vitamins and minerals with out multiplied energy."
D. "Taking TPN can growth the chance of developing a latex allergy." - ANSANSWER: "You
will acquire fingersticks for blood glucose testing."
Rationale: A patron who's receiving TPN is at hazard for hyperglycemia because of the
dextrose inside the TPN solution. Therefore, the consumer would require blood glucose
monitoring.
Rationale A: The patron need to acquire oral or enteral vitamins whenever possible because
it complements the immune device and keeps intestinal motility. However, the client ought to
obtain TPN when dietary needs are more than oral or enteral vitamins can offer, such as in a
customer who has burn injuries.
Rationale C: TPN offers energy to clients who are unable to consume or who do now not
have a functioning gastrointestinal tract. A customer who has a burn harm is in a
hypermetabolic country and calls for extra calories, carbohydrates, proteins, and fats.
,Rationale D: The nurse must check the purchaser for an egg hypersensitive reaction,
because this may result in an intolerance of the lipid answer and many lipids are composed
of egg phospholipids.
A nurse is initiating discharge planning for a consumer who had a stroke and is experiencing
proper-sided weak spot. Which of the subsequent movements have to the nurse take first?
A. Ask a social employee to pick out the patron's insurance eligibility for rehabilitation
services.
B. Request a referral for the customer to obtain bodily remedy.
C. Arrange for the transport of prescribed medicinal drugs to the client's domestic.
D. Provide the consumer with a list of network sources. - ANSANSWER: Request a referral
for the patron to get hold of bodily remedy.
Rationale: The best chance to this client is injury from falls. Therefore, the first motion the
nurse must take is to request a referral for bodily remedy.
Rationale A: The nurse need to ask a social employee to determine the purchaser's
insurance eligibility for rehabilitation offerings to allow continuity of care closer to the time of
discharge. However, there is any other action the nurse need to take first.
Rationale C: The nurse must set up for the delivery of prescribed medicinal drugs to the
client's domestic to make sure the purchaser has the medicinal drugs to be had. However,
there may be any other action the nurse must take first.
Rationale D: The nurse should provide the customer with a listing of community resources
once the health care team establishes which offerings might be used for rehabilitation.
However, there may be any other action the nurse ought to take first.
A nurse is making plans take care of a customer who has a deficit with cranial nerve (CN) II.
Which of the following actions have to the nurse plan to take?
A. Keep the patron resting in mattress.
B. Ask the customer to restate guidelines.
C. Clear objects from the customer's taking walks place.
D. Evaluate the client's capacity to swallow. - ANSANSWER: Clear items form the
consumer's strolling place.
Rationale: The nurse need to plan to clear gadgets from the client's taking walks place
because CN II is the optic nerve and a deficit can result in visible impairment that could lead
to falls.
Rationale A: A purchaser who has a CN II deficit does not require mattress rest but must
have help when out of bed.
Rationale B: The nurse must plan to invite clients to restate guidelines if they have a CN VIII
deficit because CN VIII impacts listening to.
Rationale D: The nurse need to plan to evaluate the swallowing potential of clients who have
a CN IX deficit due to the fact it is able to impair swallowing.
, A nurse is offering teaching approximately enhancing nutrients for a purchaser who has
more than one sclerosis. Which of the following commands need to the nurse consist of?
SATA
A. "A speech pathologist may be performing a swallowing examine for you."
B. "You must relaxation earlier than ingesting a meal."
C. "You ought to restrict meals which can be excessive in vitamin D."
D. "Reduce your consumption of dietary fiber."
E. "Thicken your liquids before drinking." - ANSANSWER: A, B, E
Rationale A: The nurse should coach the client that a swallowing have a look at may be
completed to determine the customer's chance for aspiration due to difficulty swallowing,
which is a manifestation of multiple sclerosis.
Rationale B: The nurse have to encourage the consumer to rest before each meal. Clients
who've more than one sclerosis regularly document weak spot and are easily fatigued.
Rationale C: The nurse must instruct the purchaser to hold adequate nutrition D levels,
because nutrition D deficiency is a chance component for more than one sclerosis.
Rationale D: The nurse have to train the patron to increase dietary fiber and fluids to lower
the risk of constipation, that is a manifestation of multiple sclerosis.
Rationale E: The nurse need to instruct the customer that drinks have to be thickened to
reduce the danger of aspiration due to trouble swallowing, that's a manifestation of a couple
of sclerosis.
A nurse is caring for a customer who's receiving general parenteral nutrients (TPN) solution
by way of continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has
stopped working. Which of the subsequent moves must the nurse take while expecting a
new infusion pump?
A, Administer the TPN solution on the identical charge using manual drip tubing.
B. Offer the client oral fluids in area of TPN answer
C. Infuse 0.9% sodium chloride solution the usage of guide drip tubing at 30 mL/hr
D. Provide dextrose 10% in water solution the use of manual drip tubing at 60 mL/hr -
ANSANSWER: Provide dextrose 10% in water solution the usage of guide drip tubing at 60
mL/hr
Rationale: The nurse should use an infusion pump when administering TPN technique to
ensure correct dosage and have to taper the infusion rate earlier than discontinuing the
solution to prevent hypoglycemia. If the nurse is unable to preserve the TPN infusion by way
of infusion pump, the nurse need to use guide drip tubing to infuse dextrose 10% in water at
the identical rate because the TPN solution.
Rationale A: The nurse must administer the TPN solution using an infusion pump to supply it
at a controlled price and decrease the hazard of hyperglycemia.
Rationale B: The nurse must hold to offer fluids by way of IV infusion to a patron who has
been receiving a continuous TPN infusion to save you rebound hypoglycemia.
2024 A
A nurse is appearing tracheostomy care for a client who is postoperative following a
laryngectomy. Which of the subsequent actions must the nurse take while suctioning the
client's airway?
A. Withdraw the catheter if the client begins coughing
B. Apply suction for 10 seconds
C. Advance the catheter 2 cm (0.8 in) after resistance is met
D. Use clinical asepsis when appearing the process - ANSCORRECT: Apply suction for 10
seconds
Rationale: The nurse ought to apply suction for most effective 5 to fifteen seconds to reduce
oxygen loss.
Rationale A: Suctioning can provoke the cough reflex because it opens the airway in addition
and lets in for more effective elimination of mucus.
Rationale C: Once resistance is met, the nurse must withdraw the catheter 1 to two cm
(zero.4 in to 0.Eight in) to save you negative bronchial tissues.
Rationale D: The nurse ought to use surgical asepsis whilst suctioning a newly created
tracheostomy to lessen the hazard for contamination.
A nurse is teaching about overall parenteral vitamins (TPN) and IV lipid emulsions with a
customer who has an extensive burn injury. Which of the following information need to the
nurse consist of?
A. "This sort of vitamins is greater effective than eating by mouth.:
B. "You will get hold of fingersticks for blood glucose testing."
C. "TPN is a way to provide vitamins and minerals with out multiplied energy."
D. "Taking TPN can growth the chance of developing a latex allergy." - ANSANSWER: "You
will acquire fingersticks for blood glucose testing."
Rationale: A patron who's receiving TPN is at hazard for hyperglycemia because of the
dextrose inside the TPN solution. Therefore, the consumer would require blood glucose
monitoring.
Rationale A: The patron need to acquire oral or enteral vitamins whenever possible because
it complements the immune device and keeps intestinal motility. However, the client ought to
obtain TPN when dietary needs are more than oral or enteral vitamins can offer, such as in a
customer who has burn injuries.
Rationale C: TPN offers energy to clients who are unable to consume or who do now not
have a functioning gastrointestinal tract. A customer who has a burn harm is in a
hypermetabolic country and calls for extra calories, carbohydrates, proteins, and fats.
,Rationale D: The nurse must check the purchaser for an egg hypersensitive reaction,
because this may result in an intolerance of the lipid answer and many lipids are composed
of egg phospholipids.
A nurse is initiating discharge planning for a consumer who had a stroke and is experiencing
proper-sided weak spot. Which of the subsequent movements have to the nurse take first?
A. Ask a social employee to pick out the patron's insurance eligibility for rehabilitation
services.
B. Request a referral for the customer to obtain bodily remedy.
C. Arrange for the transport of prescribed medicinal drugs to the client's domestic.
D. Provide the consumer with a list of network sources. - ANSANSWER: Request a referral
for the patron to get hold of bodily remedy.
Rationale: The best chance to this client is injury from falls. Therefore, the first motion the
nurse must take is to request a referral for bodily remedy.
Rationale A: The nurse need to ask a social employee to determine the purchaser's
insurance eligibility for rehabilitation offerings to allow continuity of care closer to the time of
discharge. However, there is any other action the nurse need to take first.
Rationale C: The nurse must set up for the delivery of prescribed medicinal drugs to the
client's domestic to make sure the purchaser has the medicinal drugs to be had. However,
there may be any other action the nurse must take first.
Rationale D: The nurse should provide the customer with a listing of community resources
once the health care team establishes which offerings might be used for rehabilitation.
However, there may be any other action the nurse ought to take first.
A nurse is making plans take care of a customer who has a deficit with cranial nerve (CN) II.
Which of the following actions have to the nurse plan to take?
A. Keep the patron resting in mattress.
B. Ask the customer to restate guidelines.
C. Clear objects from the customer's taking walks place.
D. Evaluate the client's capacity to swallow. - ANSANSWER: Clear items form the
consumer's strolling place.
Rationale: The nurse need to plan to clear gadgets from the client's taking walks place
because CN II is the optic nerve and a deficit can result in visible impairment that could lead
to falls.
Rationale A: A purchaser who has a CN II deficit does not require mattress rest but must
have help when out of bed.
Rationale B: The nurse must plan to invite clients to restate guidelines if they have a CN VIII
deficit because CN VIII impacts listening to.
Rationale D: The nurse need to plan to evaluate the swallowing potential of clients who have
a CN IX deficit due to the fact it is able to impair swallowing.
, A nurse is offering teaching approximately enhancing nutrients for a purchaser who has
more than one sclerosis. Which of the following commands need to the nurse consist of?
SATA
A. "A speech pathologist may be performing a swallowing examine for you."
B. "You must relaxation earlier than ingesting a meal."
C. "You ought to restrict meals which can be excessive in vitamin D."
D. "Reduce your consumption of dietary fiber."
E. "Thicken your liquids before drinking." - ANSANSWER: A, B, E
Rationale A: The nurse should coach the client that a swallowing have a look at may be
completed to determine the customer's chance for aspiration due to difficulty swallowing,
which is a manifestation of multiple sclerosis.
Rationale B: The nurse have to encourage the consumer to rest before each meal. Clients
who've more than one sclerosis regularly document weak spot and are easily fatigued.
Rationale C: The nurse must instruct the purchaser to hold adequate nutrition D levels,
because nutrition D deficiency is a chance component for more than one sclerosis.
Rationale D: The nurse have to train the patron to increase dietary fiber and fluids to lower
the risk of constipation, that is a manifestation of multiple sclerosis.
Rationale E: The nurse need to instruct the customer that drinks have to be thickened to
reduce the danger of aspiration due to trouble swallowing, that's a manifestation of a couple
of sclerosis.
A nurse is caring for a customer who's receiving general parenteral nutrients (TPN) solution
by way of continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has
stopped working. Which of the subsequent moves must the nurse take while expecting a
new infusion pump?
A, Administer the TPN solution on the identical charge using manual drip tubing.
B. Offer the client oral fluids in area of TPN answer
C. Infuse 0.9% sodium chloride solution the usage of guide drip tubing at 30 mL/hr
D. Provide dextrose 10% in water solution the use of manual drip tubing at 60 mL/hr -
ANSANSWER: Provide dextrose 10% in water solution the usage of guide drip tubing at 60
mL/hr
Rationale: The nurse should use an infusion pump when administering TPN technique to
ensure correct dosage and have to taper the infusion rate earlier than discontinuing the
solution to prevent hypoglycemia. If the nurse is unable to preserve the TPN infusion by way
of infusion pump, the nurse need to use guide drip tubing to infuse dextrose 10% in water at
the identical rate because the TPN solution.
Rationale A: The nurse must administer the TPN solution using an infusion pump to supply it
at a controlled price and decrease the hazard of hyperglycemia.
Rationale B: The nurse must hold to offer fluids by way of IV infusion to a patron who has
been receiving a continuous TPN infusion to save you rebound hypoglycemia.
