ATI RN Fundamentals Online Practice 2019 A Question with correct answer
A nurse is teaching a client and his family how to care for the client's tracheostomy
at home. Which of the following instructions should the nurse include in the teaching? a. remove the outer cannula cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide Correct Answer - b. use tracheostomy covers when outdoors -tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
a. the client is receiving formula at room temperature b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the client's caregiver washes out the feeding bag with warm water once every 24 hr d. the client's caregiver flushes the tubing with water before and after administering
medications Correct Answer - c. the client's caregiver washes out the feeding bag with warm water once every 24 hr -feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination
A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. "You would have so much more time to spend with your family."
b. "You should consider getting a part-time job or doing volunteer work."
c. "Let's talk about how the change in your job status will affect you."
d. "Why wouldn't you want to retire and relax?" Correct Answer - c. "Let's talk about how the change in your job status will affect you."
-this response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement
A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the client's pain?
a. "Is your pain constant or intermittent?"
b. "What would you rate your pain on a scale of 0 to 10."
c. "Does the pain radiate?"
d. "Is your pain sharp or dull?" Correct Answer - d. "Is your pain sharp or dull?" -asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
a. discuss the risk factors of colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phases of loss and grief
d. reassure the client that this is an expected response to grief Correct Answer - d. reassure the client that this is an expected response to grief
-during the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis A nurse on a medical-surgical unit is caring for a client who has a new prescription
for wrist restraints. Which of the following actions should the nurse take?
a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails Correct Answer - a. pad the client's wrist before applying the restraints -the use of restraints without padding can abrade the client's skin, resulting in client
injury
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client uses nonacetone nail polish remover c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment Correct Answer - b. the client uses nonacetone nail polish remover -the client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher. c. the client stores an extra oxygen tank on its side under their bed
A nurse is teaching a client and his family how to care for the client's tracheostomy
at home. Which of the following instructions should the nurse include in the teaching? a. remove the outer cannula cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide Correct Answer - b. use tracheostomy covers when outdoors -tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
a. the client is receiving formula at room temperature b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the client's caregiver washes out the feeding bag with warm water once every 24 hr d. the client's caregiver flushes the tubing with water before and after administering
medications Correct Answer - c. the client's caregiver washes out the feeding bag with warm water once every 24 hr -feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination
A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? a. "You would have so much more time to spend with your family."
b. "You should consider getting a part-time job or doing volunteer work."
c. "Let's talk about how the change in your job status will affect you."
d. "Why wouldn't you want to retire and relax?" Correct Answer - c. "Let's talk about how the change in your job status will affect you."
-this response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement
A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the client's pain?
a. "Is your pain constant or intermittent?"
b. "What would you rate your pain on a scale of 0 to 10."
c. "Does the pain radiate?"
d. "Is your pain sharp or dull?" Correct Answer - d. "Is your pain sharp or dull?" -asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
a. discuss the risk factors of colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phases of loss and grief
d. reassure the client that this is an expected response to grief Correct Answer - d. reassure the client that this is an expected response to grief
-during the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis A nurse on a medical-surgical unit is caring for a client who has a new prescription
for wrist restraints. Which of the following actions should the nurse take?
a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails Correct Answer - a. pad the client's wrist before applying the restraints -the use of restraints without padding can abrade the client's skin, resulting in client
injury
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client uses nonacetone nail polish remover c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment Correct Answer - b. the client uses nonacetone nail polish remover -the client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher. c. the client stores an extra oxygen tank on its side under their bed
