RN ATI Fundamentals of Nursing

Question 1 of 5

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

A. Hold the container of solution 30 cm (12 in) above the anus.B. Hold the container of solution 15 cm (6 in) above the anus,then lower it 15 cm below the anus.C. Hold the container of solution level with the client's upper hip.D. Keep the container of solution at a level to maintain client comfort.

Correct Answer: A

Rationale: The correct answer is A: Hold the container of solution 30 cm (12 in) above the anus. This is the correct action because it allows for a gentle, gravity-driven flow of solution into the rectum for effective cleansing. Holding the container at this height ensures a steady flow without causing discomfort or pressure.

Choice B is incorrect because lowering the container below the anus may cause rapid instillation of the solution, leading to discomfort and potential injury.
Choice C is incorrect as the solution needs to flow downwards into the rectum, not be held level with the hip.
Choice D is incorrect as maintaining client comfort is important, but in this case, the correct positioning of the container is essential for the enema to be effective.

Question 2 of 5

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

A. Elevate the bed to a position of comfort for the nurse.B. Acquire the help of several people to lift the client.C. Place the wheelchair at a 90° angle to the bed.D. Lock the wheels of the bed and the wheelchair.

Correct Answer: D

Rationale: The correct answer is D: Lock the wheels of the bed and the wheelchair. This is essential to ensure the safety of the client during transfer. Locking the wheels prevents both the bed and the wheelchair from moving, reducing the risk of falls or accidents. By securing both, the nurse maintains stability and control during the transfer process. Elevating the bed for the nurse's comfort (
A) is not a priority over client safety. Acquiring help from several people (
B) may be necessary for heavy clients, but it's not the primary action. Placing the wheelchair at a 90° angle (
C) is not as crucial as securing the wheels.

Question 3 of 5

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence

A. which of the following interventions should the nurse initiate?B. Request a prescription for an indwelling urinary catheter.C. Take the client to the bathroom every 2 hr.D. Remind the client to tell the nurse when he has to urinate.E. Use adult diapers to prevent frequent clothing changes.F. Use adult diapers to prevent frequent clothing changes.

Correct Answer: B

Rationale: The correct answer is B: Request a prescription for an indwelling urinary catheter. In cases where there is no medical cause for urinary incontinence in an older adult with dementia, an indwelling urinary catheter may be necessary to manage the incontinence effectively. This intervention helps in continuously draining urine from the bladder, reducing the risk of skin breakdown and maintaining hygiene. Other options are incorrect as they do not address the underlying issue of managing urinary incontinence effectively. Option C only helps with scheduled toileting but does not address the continuous need for bladder drainage. Option D relies on the client's ability to communicate, which may be compromised in dementia. Option E focuses on managing the consequences of incontinence rather than treating the root cause.

Question 4 of 5

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

A. inguinal canalB. kneeC. lower third of the tibiaD. dorsal aspect of the foot

Correct Answer: C

Rationale: The correct location to palpate the posterior tibial pulse is the lower third of the tibia. The posterior tibial pulse is located behind the medial malleolus of the ankle. Palpating in this area allows the nurse to accurately assess the strength, rhythm, and rate of the pulse. The other choices are incorrect because:
A) the inguinal canal is not a location for assessing the posterior tibial pulse,
B) the knee is too far from the ankle where the pulse is located, and
D) the dorsal aspect of the foot is where the dorsalis pedis pulse is palpated, not the posterior tibial pulse.

Question 5 of 5

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A. Checking the pupillary response to lightB. Eliciting the gag reflexC. Testing visual acuityD. Observing for facial symmetry

Correct Answer: A

Rationale: The correct answer is A: Checking the pupillary response to light. Cranial nerve III, also known as the oculomotor nerve, controls the pupillary response to light.
To assess this nerve, the nurse should shine a light into the client's eyes and observe the pupillary constriction in response to the light stimulus. This tests the integrity of cranial nerve III, which controls the constriction of the pupils.

Other choices are incorrect because:
B: Eliciting the gag reflex - This tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C: Testing visual acuity - This assesses the function of the optic nerve (cranial nerve II), not cranial nerve III.
D: Observing for facial symmetry - This evaluates cranial nerve VII (facial nerve) function, not cranial nerve III.

RN ATI Fundamentals of Nursing | Nurselytic

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