ATI RN Fundamentals 2023 | Nurselytic

Correct Answer: A,C

Rationale: The correct answers are A and C. Option A is important as adjusting oxygen flow rate can help ease breathing, ensuring optimal oxygen delivery. Option C advises storing the oxygen cylinder wrench with the tank for easy access in case of emergencies. These two pieces of information are crucial for maintaining proper oxygen therapy and ensuring safety.

Options B, E, F, and G are incorrect. Option B states a specific duration for antibiotic therapy, which may vary depending on the type of infection. Option E relates to steroid medication administration timing, which can vary based on the specific medication and condition. Option F provides general advice on antibiotic administration but may not apply to all antibiotics. Option G implies a specific tapering schedule for steroids, which should be individualized based on the patient's condition and response.

Correct Answer: D

Rationale:
Correct Answer: D

Rationale: Cutting the old ties after securing the new ties ensures that the client's airway remains stable throughout the procedure. If the old ties are cut before securing the new ties, there is a risk of accidental decannulation, leading to potential airway compromise. This step-by-step approach prioritizes patient safety and prevents unnecessary risks during the tracheostomy tie change.
Summary:
A: Allowing space for three fingers under the ties is important for proper fit but not the immediate action needed during the tie change.
B: Using a quick-release knot may be helpful for easy removal in emergencies but is not the primary concern during the tie change.
C: Extending the client's neck may help with visualization but is not essential for securing the ties.
D: Cutting the old ties after securing the new ties is the correct action to maintain airway stability.
E, F, G: No information provided.

Correct Answer: D

Rationale: The correct answer is D: "We can discuss what you can expect during your stay." This response acknowledges the client's anxiety and offers support by providing information. It empowers the client by involving them in the discussion and helps alleviate fear of the unknown.
Choice A dismisses the client's feelings and lacks empathy.
Choice B generalizes and may not address the client's specific concerns.
Choice C may come off as confrontational and put the client on the spot.

Correct Answer: C

Rationale: The correct answer is C: Eat a light carbohydrate snack before bedtime. Carbohydrates can help increase the production of serotonin, a neurotransmitter that promotes relaxation and sleep. Consuming a light carbohydrate snack before bedtime can help regulate blood sugar levels and promote a sense of calmness conducive to falling asleep.


Choice A (Drink a cup of hot cocoa) contains caffeine which can interfere with sleep.
Choice B (Exercise 1 hr before bedtime) can increase alertness and make it harder to fall asleep.
Choice D (Take a 30-min nap daily) can disrupt the sleep-wake cycle and make it difficult to sleep at night.

Correct Answer: D

Rationale: The correct answer is D: Check the blood product's compatibility with the client's blood type. This step is crucial to prevent a transfusion reaction, as administering incompatible blood can be life-threatening. The nurse should verify the blood product against the client's blood type and Rh factor to ensure compatibility.

A: Priming the IV tubing with lactated Ringer's is not necessary before administering packed RBCs and does not ensure the blood product's compatibility.
B: Confirming the client's identity with the blood bank technician is important but does not directly relate to ensuring the blood product's compatibility.
C: Checking for a small gauge IV catheter is important for infusion, but it is not directly related to ensuring the blood product's compatibility.
Overall, the priority before administering packed RBCs is to confirm compatibility with the client's blood type to prevent adverse reactions.