ATI Nsg 131 Fundamentals Exam | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Witness the client's signature. This is crucial to ensure that the client is voluntarily giving consent for the surgical procedure. By witnessing the signature, the nurse confirms that the client is fully informed and agrees to the procedure. Obtaining consent (
Choice
A) is important but witnessing the client's signature (
Choice
C) validates that the consent is authentic. Explaining the procedure (
Choice
B) and risks and benefits (
Choice
D) are essential parts of the informed consent process but witnessing the signature is the final step to confirm the client's agreement.

Correct Answer: A

Rationale: The correct answer is A: Use attentive listening with the client. Attentive listening is a key aspect of the communication principle of presence as it shows the client that the nurse is fully engaged, focused, and empathetic. By actively listening, the nurse can understand the client's needs and perspectives, which is essential for building a collaborative relationship. It allows the nurse to demonstrate respect, empathy, and validation towards the client's feelings and experiences.


Choice B is incorrect because focusing on the client's present circumstances only and ignoring personal stories may hinder the establishment of a deeper connection and understanding.
Choice C is incorrect as offering personal thoughts and beliefs can shift the focus away from the client and may lead to biases or misunderstandings.
Choice D is incorrect because verbalizing understanding of how the client feels is important, but it is not the primary action associated with the communication principle of presence.

Correct Answer: C

Rationale: The correct answer is C. The nurse should notify the provider about a urine output of 175 mL in the past 8 hours for a client with impaired renal function as it indicates decreased urine output, which can be a sign of worsening renal function. This finding may suggest renal failure or dehydration, requiring immediate intervention.
Choice A is incorrect as cloudy urine after sitting is not unusual and may result from urinary sediment.
Choice B is incorrect as a strong odor in the first-voided urine is common and not necessarily concerning.
Choice D is incorrect as a urine output of 2,200 mL in 24 hours is within the normal range.

Correct Answer: C

Rationale: The correct answer is C. Eating 2 cans of soup a day can lead to excessive sodium intake, which can worsen hypertension. A heart-healthy diet for hypertension should be low in sodium. Thickening gravies with cornstarch (
A) is a good low-sodium alternative. Fresh fruits (
B) are a nutritious snack option. Replacing table salt with dried herbs (
D) is a good way to reduce sodium intake.

Correct Answer: C

Rationale: The correct answer is C: The client's current weight-bearing status. This is crucial in determining the safest method of transfer as it helps the nurse assess the client's ability to support their weight during the transfer process, reducing the risk of falls and injuries. By knowing the client's weight-bearing status, the nurse can choose the appropriate assistance level and equipment needed for a safe transfer.


Choice A (The client's height) is not as important in this scenario as weight-bearing status because height does not directly impact the safety of the transfer process.


Choice B (The client's ability to communicate) is important for overall patient care but is not the most crucial factor in determining the safest transfer method.


Choice D (The type of equipment used in previous transfers) is not as important as the client's current weight-bearing status, which directly affects the safety and success of the transfer.

Overall, the client's weight-bearing status is the most critical factor to consider when determining the safest method of transfer.