ATI CBC Level 1 Practice A with Complete Rationales

Nurse assessing preschooler with UTI, which of the following findings should the nurse expect? - Abdominal Pain Rationale: also included constipation, dysuria, foul-smelling urine, and fever Nurse is counseling a client who has a family history of colorectal cancer about nutrition management to help prevent GI cancers. Which image indicates what the nurse should encourage the client to include liberally in diet? - Fruit Rationale: limit alcohol to no more than 2 serving/day for male and 1 serving/day per female, consume low fat diet (not fried chicken), consume whole grains (oatmeal and whole wheat), NOT white bread (refined grain products) A nurse is preparing to extinguish a small fire in clients room. Which of the following actions should the nurse take when using the fire extinguisher? - Slide the pin on top of the fire extinguisher straight out Rationale: This allows use of the extinguisher, should aim at base of the fire, squeeze the handles, sweep from side to side to expel it evenly (not circular) A nurse is caring for a child with celiac disease. Which should the nurse remove from the child's meal tray? - Oatmeal with raisins Rationale: CANT HAVE GLUTEN (in wheat, rye, and barley) can give scrambled eggs, corn (corn flake cereal), and orange juice. This disease can cause diarrhea, weight loss, abd pain, and fatigue when consuming gluten. A nurse at a providers office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into a sleep promotion plan? - "Sleep in the location of your home where you feel you rest best" Rationale: encourage client to sleep where they sleep best (couch, bed, chair), DO NOT consume alcohol in late afternoon or evening (it can inhibit sleep, if needed consume earlier in the day. DO NOT turn on TV, light and noise at bedtime can reduce sleep, also Maintain regular sleep and wake times to improve sleep patterns A nurse is assessing the spiritual well-being and development of a preschooler. The nurse asks the preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the nurse expect? - "It's wrong because my dad said I can't kick her" Rationale: The nurse should expect the preschooler to be motivated to choose right from wrong because of the rules taught to him by his parents. He will not yet choose right from wrong bc of how his actions affect others (more focused on how will affect himself) A nurse in a long term care facility is admitting a new client following a brief stay in acute care. In adherence with the joint commission national patient safety goals regarding med admin, which of the following actions should the nurse take? - Compare a list of the clients current medications with the ones he will take in long-term care. Rationale: this includes maintaining and communicating Accurate client medication information. A nurse is caring for a client who is 2 days post op following an above-the-knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the clients pain? - Administer a beta-blocking medication to the client Rationale: These have been shown to relieve the phantom limb pain manifestations of dull and burning type pain. The nurse should position client on a firm mattress to prevent hip flexor contractures. Might be able to use heat, ultrasound therapy, or transcutaneous electrical nerve stimulation for PLP. Bandage should be secured snugly to reduce edema and promote limb shrinkage. Loosening it will not help PLP. A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching? - "I can give her watermelon pieces after I remove the seeds" Rationale: can easily choke on seeds or pits. Can easily choke on grapes (peeling them don't help), have to cut grapes into small pieces before offering them to a toddler, can easily choke on popcorn bc of its tendency to swell and not dissolve (not putting salt or butter helps nutritionally but not for choking), can easily choke on hot dog slices (slicing thinly doesn't help) A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue? - Cumulative Index to Nursing and Allied Health Literature (CINAHL) Rationale: use to locate clinical research about health-related client care issues. A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? - Delay the clients meal time if he is fatigued Rationale: To promote safety, the nurse should encourage the client to rest prior to meal time. If fatigued, give client time to rest. Should instruct to tilt head forward, avoid using a syringe to force fluids into their mouth, nurse should attempt to eliminate distractions and disruptions while PT is eating (TV) A nurse in a long term care facility is performing a fall risk assessment on a newly admitted client using the timed up and go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? - Observe the client ambulating a distance of 3 m (10 feet) during the TUG test Rationale: instruct client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. Observe clients ability and use stopwatch. If longer than 14 seconds then at increased risk for falls. Use assistive aid if have one. Nurse avoid assisting them to stand. Client should avoid using the arms of the chair for assistance when standing. A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is accompanied by his 16 year old mother and his maternal grandfather. Which of the following actions should the nurse take when assisting with informed consent? - Witness consent obtained from the infants mother. Rationale: The nurse should assist in obtaining informed consent from the mother by witnessing her signature. A minor even if unemancipated can provide consent for her infant. They can also legally provide informed consent for STI tx, substance use tx, and care related to pregnancy in some states. Use the grandparent if legal guardian or if parent is unavailable. Use court if parent is not acting in child's best interest. A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan? - Perform hand hygiene before touching the IV tubing. Rationale: hand hygiene before touching any part of the infusion system or the client to reduce the risk of infection. Change bags of IV solution every 24 hr, use antimicrobial agents (alcohol, povidone-iodine, or chlorhexidine) NOT hydrogen peroxide for sure care, check IV site every 4 hr for manifestations of infection at the insertion site