ATI Fundamental LATEST UPDATE 100% CORRECT SOLUTIONS

ATI Fundamental LATEST UPDATE 100% CORRECT SOLUTIONS A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid - ANSWER Hydrocolloid - dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. 1. Alginate - dressing are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. 2. Gauze - moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. 3. Transparent - dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. 4. Hydrocolloid - dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? 1. "I am not worried because I still have hope that he will be okay." 2. "I am relying on support from our family during this time." 3. "We can plan our family reunion once he recovers and comes home." 4. "We don't see any reason to start discussing funeral arrangements right now." - ANSWER 2. "I am relying on support from our family during this time." 1. False hope 3. Denial feelings 4. Yes, it's right that not a good time to talk about funeral arrangement but it is not effective coping to patient A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse to identify the client's safety needs? (Select all that apply) 1. Lacrimal apparatus 2. Pupil clarity 3. Appearance of bulbar conjunctivae 4. Visual fields 5. Visual acuity - ANSWER 2. Pupil clarity 4. Visual fields (finger test) 5. Visual acuity (Snellen chart) 1. Lacrimal apparatus - If clients have an impairment in the ability to produce tears, it should not affect their fall risk. 3. Appearance of bulbar conjunctivae A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 1. The top of the cane is parallel to the client's waist. 2. When walking, the client moves the cane 46 cm (18 in) forward. 3. The client holds the cane on the stronger side of her body. 4. The client moves her stronger limb forward with the cane. - ANSWER 3. The client holds the cane on the stronger side of her body. 1. The top of the cane should be parallel to the client's greater trochanter. 2. To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. 4. The client should move her weaker leg forward with the cane. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 1. Make sure the client's room has at least six air exchanges per hour. 2. Make sure the client wears a mask when outside her room if there is construction in the area. 3. Place the client in a private room with negative-pressure airflow. 4. Wear an N95 respirator when giving the client direct care. - ANSWER 2. Make sure the client wears a mask when outside her room if there is construction in the area - protect patient from risk for infection from environment. 1. 12 air exchanges not 6 3. private room yes, but positive pressure airflow. 4. The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1. "I can place an extension cord across my living room to plug in my television." 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." 3. "I will place my alarm clock on my bedroom dresser across the room." 4. "I will replace the old throw rug in my kitchen with a new one." - ANSWER 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? 1. Administer the medication with the needle at a 45° angle. 2. Administer the medication into the client's nondominant arm. 3. Pull the client's skin laterally or downward prior to administration. 4. Massage the injection site after administration. - ANSWER 1. The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. 2. AThe nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus. 3. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. 4. The nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising. A nurse manager is preparing to review medication documentation with a group a newly licensed nursing. Which of the following statements should the nurse manager plan to include in the teaching? 1. "Use the complete name of the medication magnesium sulfate." 2. "Delete the space between the numerical dose and the unit of measure." 3. "Write the letter U when noting the dosage of insulin." 4. "Use the abbreviation SC when indicating an injection." - ANSWER 1. "Use the complete name of the medication magnesium sulfate." A nurse is taking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? 1. Role ambiguity 2. Sick role 3. Role overload 3. Role conflict - ANSWER 3. Role overload - The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage. A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? 1. Advocacy ensures clients' safety, health, and rights. 2. Advocacy ensures that nurses are able to explain their own actions. 3. Advocacy ensures that nurses follow through on their promises to clients. 4. Advocacy ensures fairness in client care delivery and use of resources. - ANSWER 1. Advocacy ensures clients' safety, health, and rights - Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. A nurse is caring for a client who has a new diagnosis of seizure disorder. Nurse Notes 0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900:On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Medication Administration Record: Carbamazepine ER 200 mg PO twice per dayLorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min - ANSWER The nurse should first address the client's "physical safety", followed by the client's "positioning" A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. 2. Remove the NG tube if the client begins to gag or choke. 3. Apply suction to the NG tube prior to insertion. 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus. - ANSWER 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus. A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1. Verify the client's name on their identification bracelet with the medication administration record. 2. Call the pharmacy to determine whether the client's medications are available. 3. Compare the client's home medications with the provider's prescriptions. 4. Place the client's home medication bottles in a secure location. - ANSWER 3. Compare the client's home medications with the provider's prescriptions. A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? 1. Insert the needle at a 15° angle. 2. Aspirate for blood return prior to administration. 3. Administer the medication into the abdomen. 4. Massage the site following the injection. - ANSWER 3. Administer the medication into the abdomen - The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or