ATI QUESTIONS TO REVIEW BEFORE EXIT & NCLEX: 300 QUESTIONS WITH ANSWERS 2024/2025 (GRADED A)

ATI QUESTIONS TO REVIEW BEFORE EXIT & NCLEX: 300 QUESTIONS WITH ANSWERS 2024/2025 (GRADED A) A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate? A.) Apply cold compresses to the affected extremity B.) Apply warm compresses to the affected extremity C.) Keep the affected extremity above the level of the heart D.) Keep the affected extremity below the level of the heart - Answer-ANSWER--->D.) Keep the affected extremity below the level of the heart RATIONALE: The nurse should NEVER apply direct heat to the limb. Sensitivity is decreased in the affected limb & burns may result A nurse is preparing to administer a blood transfusion to a pt who has anemia. Which of the following action should the nurse take 1st? a. Obtain the pts VS b. Describe the blood transfusion procedure to the pt c. Check for the type & # of units of blood to administer d. Initiate a peripheral IV line - Answer-ANSWER=C RATIONALE: According to EBP, the nurse should 1st confirm that the type & # of units of blood to administer matches what is indicated in the pts medication administration record (MAR) A nurse is caring for a pt who recently had a stroke of the right hemisphere. which of the following manifestations should the nurse expect? a. Impulsive behavior b. Anxiety concerning the future c. Feelings of guilt d. Expressive aphasia - Answer-ANSWER=A RATIONALE: The nurse should expect a pt who has had a right-hemispheric stroke to manifest impulsive behavior A nurse is providing teaching to a pt who has AIDS. which of the following statements by the pt indicates an understanding of the teaching? a. I should clean my toothbrush in the dishwasher once a month b. I should eat more fresh fruit & vegetables c. I will avoid drinking a glass of cold liquid that has been standing for 30 mins d. I will take my temp. once a day - Answer-ANSWER=D RATIONALE: A pt who has AIDS is immunocompromised and is @ risk for infection. The pt should check his temp. daily to identify a temp. greater than >37.8 C (100 F) which is an early manifestation of an infection A pt w/AIDS should avoid drinking a glass of water/liquid that stands for 60 mins or more to reduce the risk of drinking contaminated liquids questions-with-answers - Answer- review-before-exit-en-nclex-300-questions-with-answers Pressure Ulcers--INTERVENTIONS: - Answer-****AVOID DIRECT MASSAGE TO A REDDENED SKIN AREA B/C MASSAGE CAN DAMAGE THE CAPILLARY BEDS & CAUSE TISSUE NECROSIS*** -Identify pts at risk for developing a pressure ulcer -Institute measures to prevent pressure ulcers, such as appropriate positioning, using pressure relief devices, ensuring adequate nutrition, & developing a plan for skin cleansing & care -Perform frequent skin assessments & monitor for an alteration in skin integrity -Keep the pts skin dry & the sheets wrinkle-free; if the pt is incontinent, check the pt frequently & change pads or any items placed under the pt after they are soiled -Use creams & lotions to lubricate the skin & a barrier protection ointment for the incontinent pt -Turn & reposition the immobile pt every 2 hours** or more frequently if necessary; provide active & passive ROM exercises at least every 8 hours ** -If a pressure ulcer is present, record the location & size of the wound (length, width, depth in cms), monitor & record the type & amount of exudates (a culture of the exudate may be prescribed), & assess for undermining & tunneling -Serosanguineous exudate (blood-tinged amber fluid) is expected for the 1st 48 hours; purulent exudates indicate colonization of the wound w/bacteria -Use agency protocols for skin assessment & management of the wound -Tx may include: wound dressings & debridement; skin grafting may be necessary -Other tx's may include: electrical stimulation to the wound area (inceases blood vessel growth & stimulates granulation), vacuum-assisted wound closure (removes infectious material from the wound & promotes granulation), hyperbaric O2 therapy (administration of O2 under high pressure raises tissue O2 concentration), & the use of topical growth factors (biologically active substances that stimulate cell growth questions-with-answers - Answer- review-before-exit-en-nclex-300-questions-with-answers BURN DEPTH--1.) Superficial-Thickness Burn: - Answer--Involves injury to the epidermis; the blood supply to the dermis is still intact -Mild to severe erythema (pink to red_ is present, but NO blisters -Skin blanches w/pressure -Burn is painful, w/tingling sensation, and the pain is eased by cooling -Discomfort lasts about 48 hours; healing occurs in about 3-6 days -No scarring occurs & skin graft are NOT required BURN DEPTH--2.) Superficial Partial-Thickness Burn: - Answer--Involves injury deeper into the dermis; the blood supply is reduced -Large blisters may cover an extensive area -Edema is present -Mottled pink to red base & broken epidermis, w/a wet shiny, & weeping surface, are characteristic -Burn is painful and sensitive to cold air -Heals in 10-21 days w/NO scarring, but some minor pigment changes may occur -Grafts may be used if the healing process is prolonged BURN DEPTH--3.) Deep Partial-Thickness Burn: - Answer--Extends deeper into the skin dermis -Blister formation usually does NOT occur b/c the dead tissue layer is thick & sticks to underlying viable dermis -Wound surface is red & dry w/white areas in deeper parts -May or may not blanch, & edema is moderate -Can convert to full-thickness burn if tissue damage increases w/infection, hypoxia or ischemia -Generally heals in 3-6 weeks, but scar formations results & grafting may be necessary BURN DEPTH--4.) Full-Thickness Burn: - Answer--Involves injury & destruction of the epidermis & dermis; the wound will NOT heal by reepithelialization & grafting may be required -Appears as a dry, hard, leathery eschar (burn crust or dead tissue must slough off or be removed from the wound before healing can occur) -Appears waxy white, deep red, yellow, brown, or black -Injured surface appears dry -Edema is present under the eschar -Sensation is reduced or absent b/c of nerve ending destruction -Healing may take weeks to months & depends on establishing an adequate blood supply -Burn requires removal or eschar & split- or full-thickness skin grafting -Scarring & wound contractures are likely to develop BURN DEPTH--5.) Deep Full-Thickness Burn: - Answer--Injury extends beyond the skin into underlying faschia & tissues, and muscle, bone & tendons are damaged -Injured area appears black & sensations is completely absent -Eschar is hard & inelastic