ATI CRITICAL CARE QUESTIONS WITH ANSWERS

ATI CRITICAL CARE QUESTIONS WITH ANSWERS 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? a. Change bags of IV solution every 72 hours. b. Perform hand hygiene before touching IV tubing. c. use hydrogen peroxide to cleanse IV insertion site. d. Assess the IV insertion site every 12 hr for redness. - CORECT ANSWER-b. Perform hand hygiene before touching IV tubing Explanation: The nurse should perform thorough hand hygiene before touching any part of the infusion system or the client to reduce the risk of catheter-related blood stream infections. A newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. Which of the following responses should the charge nurse make? a. "The National Institutes of Health website contains this information." b. "The state board of nursing can provide this information." c. The facility's legal department write a summary of scope of practice." d. "The Nurse Licensure Compact defines a nurse's scope of practice." - CORECT ANSWER-b. "The state board of nursing can provide this information." explanation: Each state develops a nurse practice act, which defines scope of practice for nurses in that state. This practice act is available on the board of nursing website for each state. A nurse is caring for a client who is 2 days postoperative 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 client's neuropathic pain? a. inform the client that phantom limb pain is not real. b. administer a beta-blocking medication to the client. c. place the client on a soft mattress. d. loosen the bandage on the client's residual limb. - CORECT ANSWER-b. administer a beta-blocking medication to the client. explanation: The nurse should administer a beta-blocking medication to the client. This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain. A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown? a. use a sheepskin device to pad the client's pressure points. b. apply cornstarch to the perineal area after bathing the client. c. massage the client's skin and pressure points every 12 hr. d. offer the client a glass of water every 2 hr when re-positioning. - CORECT ANSWER-d. offer the client a glass of water every 2 hr when re-positioning. explanation: The nurse should offer the client a glass of water every 2 hr on the client's re-positioning schedule. This helps prevent dehydration, which increases the risk of skin breakdown. a nurse is teaching a young adult female client about health screening for breast cancer. Which of the following statements by the client indicates an understanding of breast self-examination (BSE)? a. "I should perform a BSE about 1 week before my period each month." b. "I should use the fingers of my right hand to feel for lumps in my right breast." c. "I should report a lump in my breast if it remains for two consecutive BSEs." d. "I should expect to feel a firm ridge along the bottom curve of each breast." - CORECT ANSWER-d. "I should expect to feel a firm ridge along the bottom curve of each breast." explanation: The nurse should instruct the client that a firm ridge is expected along the bottom curve of each breast. The client should be able to feel this area during the BSE. Performing a BSE promotes breast self-awareness so that the client knows how her breasts normally feel. This awareness increases the client's ability to identify changes that require further evaluation and treatment. A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he is the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the parent? a. encourage the parent to speak with the family of the driver of the car. b. inform the parent that anger is a natural response when dealing with loss. c. ask the parent to leave and come back later after she has calmed down. d. contact a clergy member to come and speak with the parent. - CORECT ANSWERb. inform the parent that anger is a natural response when dealing with loss. explanation: The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings