TESTBANK FOR ATI COMPREHENSIVE 2.0 QUESTIONS AND ANSWERS

NURS 314 Health Assessment ATI COMPREHENSIVE 2.0 1. Following abdominal surgery, a client's abdominal wound edges are separating, and the wound is draining a large amount of serous drainage. Thenurse should place the client: Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it can increase tension on thesuture line, and cause further wound separation and tearing (dehiscence).Correct: The semi-Fowler's position decreases tension on the wound, and it may prevent further separation and tearing of the wound(dehiscence).Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further wound separation and tearing (dehiscence). flat on the back with legs straight. in high-Fowler's position with legs straight. in semi-Fowler's position with the knees slightly bent. on the left side with knees bent . 2. The PN is preparing to administer an enteral feeding to a client. To prevent gastric cramping and discomfort due to the feeding, the nurse should: Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via gastrostomy tube, the formula reaches the stomach quickly, with little or no opportunity to be warmed, as oral feedings would as they pass through the mouth and esophagus.Incorrect: Tube placement is confirmed prior to beginning each feeding. This action does not prevent gastric discomfort. However, checking tube placement does help prevent the infusion of the formula into the lungs.Incorrect: To prevent gastric discomfort, the concentration of the tube feeding formula needs to be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the first few feedings areadministered.Incorrect: The head of the bed should be elevated at least 30° during the feeding and for at least 30 minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent cramping and discomfort. allow time for the formula to reach room temperature prior to administration. determine tube placement once every 24 hours. prepare to administer full-strength rather than diluted formula. elevate the head of the bed during and after feedings. 3. The nurse is caring for a child with cystic fibrosis (CF). Which intervention willhelp to prevent respiratory complications? Incorrect: Clients with CF should not receive cough suppressant syrups. These children need to cough frequently to clear lung secretions.Correct: Nebulization with mist or aerosol therapy followed by chest physiotherapyhelps to keep secretions free-flowing. The pulmonary effects of CF are progressive, and bronchial secretions must bekept moist.Incorrect: The child should change positions frequently to promote drainage from the lungs, and promote aeration of the lungs.Incorrect: Children with CF can safely receive the pertussis vaccine. These children need protection from pertussis because this infection causes severe respiratory complications. Encourage the use of cough suppressant syrup. Give frequent nebulization treatments. Limit changing the child's position to conserve the child's need for oxygen. Withhold the vaccine for pertussis. 4. The nurse is caring for a client following insertion of a pacemaker. The client isplaced on continuous ECG monitoring because it will: Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time of insertion.Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker insertion.Correct: The heart rate may change following pacemaker insertion because the pacemaker fails to maintain the pre-set heartrate. This problem can be detected immediately with continuous ECG monitoring.Incorrect: Fluoroscopy is used to determine dislodgement of pacer leads after a pacemaker insertion. Dislodgement can be prevented with bedrest andminimal arm and shoulder activity. allow the primary care provider to adjust voltage settings. check placement of the pacer wires. detect a dramatic change in heart rate. determine dislodgement of pacer leads. 5. The nurse is administering eye drops to a client. To prevent injury, the nurse should: Incorrect: The nurse should ask the client to "look up" before instilling the eye drops. This action reduces stimulation of the corneal reflex and injury to the eye, should the client jerk away.Incorrect: Eye drops should never bedropped directly onto the cornea as this action may injure the cornea. The nurse should deposit the medication o