ATI NCLEX Review Questions & Rationales Questions & Correct Answers/ Graded A+

List the pertinent information that should be included in a transfer report. : Medical diagnosis, care providers, demographic information, overview of health status, plan of care, recent progress, alterations in health status that cause immediate concern, notifications of assessments or care within the next few hours, recent vitals and medications (scheduled and PRN), allergies, diet and activity orders, specific equipment or adaptive devices, advance directives, emergency code status, family involvement in healthcare, and healthcare proxy if applicable. What are three (3) of the provider's responsibility for obtaining an informed consent? : The provider must make sure that the patient understands the reason for the treatment or procedure, how the treatment or procedure will benefit the patient, and the risks involved if the patient chooses not to receive the treatment or procedure. The physician should also discuss alternatives to care if they chose to not have the procedure done. Identify three (3) priority teaching points to include when educating a client to use a cane. : Maintain two points of support on the ground at all times, keep the cane on the stronger side of the body, move the cane forward about 6-10 inches and then move the weaker leg toward the cane before advancing the stronger leg past the cane. 2 The nurse is teaching a new parent appropriate finger foods to introduce around nine (9) months. Identify five (5) finger foods that would be appropriate to introduce at nine (9) months. : Ripe bananas, graham crackers, noodles, pears, peaches How should the nurse respond when the client requests information about meditation? : Meditation uses rhythmic breathing to calm the mind and the body. A client is at risk for a deep vein thrombosis. What is the priority assessment for this client? Describe the procedure to use when applying elastic stockings (TEDS). : Perform hand hygiene. Assess skin, circulation, leg edema. Measure calf/thigh circumference and the length of the leg to select correct TEDS size. Turn the stockings inside to the heel, place on the foot, pull the remainder of the stocking over the heel and on the leg, smoothing any creases or wrinkles. Remove every 8H to assess for redness, warmth, tenderness. Keep clean/dry. Document presence of TEDS. A client has been prescribed a mechanical soft diet. What are three (3) indications for this therapeutic diet? : Mechanical soft diet includes clear and full liquids plus diced and ground foods, indicated by trouble chewing/swallowing, difficulty moving or loss of feeling in areas of the mouth, or surgery in the mouth. 3 The nurse has been assigned to a post-abdominal surgery client who has also been diagnosed with dementia. The family is concerned about pain control for the client because the client is confused. What should the nurse include in their teaching to the family about the pain control plan for this client? : Vital signs are indicative of pain, therefore assessed frequently. Explain behavioral changes due to the dementia which may indicate pain. Pre-medicate the patient prior to activities and before pain is expected. It is important for the family to understand that there are pain scales that can be used to help determine if pain medication is needed. A client reports difficulty falling asleep. What are nursing interventions to promote sleep? : Promote a bedtime routine, exercise at least 2H before bedtime, personal hygiene needs to promote comfort, muscle relaxation if anxious/stressed A nurse is conducting an admission assessment for an older adult client with a hearing impairment. What are some strategies the nurse can use to improve communication with this client? : Face the patient and speak slower in a normal volume, do not approach the patient from behind, make sure the patient is aware you are speaking before you initiate conversation. The physician prescribes meperidine 25 mg IM now for a client's pain. Available: Meperidine 100 mg/mL How much meperidine will the nurse administer? : 25 mg * 1mL/100mg = 0.25m