ATI RN
Communication in Nursing Practice Questions Questions
Question 1 of 5
The first-semester nursing student tells the team leader that her clinical assignment for the day is to take vital signs and obtain a client history that will take about 1 or 2 hours to complete. Which clients would the leader recommend that she approach to fulfill her assignment? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B because Mr. L, who has a tracheostomy and partial laryngectomy, will likely require vital signs monitoring and a detailed client history due to his complex respiratory and communication needs. This assignment will provide the student with valuable experience in caring for clients with specialized needs. Incorrect choices: A: Mr. N (non-Hodgkin lymphoma) - While Mr. N may require vital signs monitoring, his condition does not necessarily involve complex care needs that would warrant a 1-2 hour history-taking session. C: Mr. B (bladder cancer) - Vital signs monitoring and history-taking for a client with bladder cancer may not require as much time as the scenario suggests, as the care needs may not be as complex as those of a client with a tracheostomy and laryngectomy. D: Ms. C (bowel resection and colostomy) - While Ms. C may require vital signs monitoring and history-taking
Question 2 of 5
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer, A: 1. Monitoring the access site during administration allows for early detection of extravasation. 2. Early detection can prevent serious tissue damage and complications. 3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial. 4. This action is within the nurse's scope of practice and promotes patient safety. Summary: - Choice B is incorrect as delaying treatment can impact Mr. L's health. - Choice C is not directly related to preventing extravasation. - Choice D, though important, does not directly address preventing extravasation during administration.
Question 3 of 5
The nurse sees that Mr. B (bladder cancer) has received docusate for the past 2 days. Which question is the nurse most likely to ask to evaluate the effectiveness of the docusate?
Correct Answer: B
Rationale: The correct answer is B. Docusate is a stool softener commonly used to prevent constipation, which is a common side effect of opioid pain medications. By asking if the patient had a bowel movement today or yesterday, the nurse can evaluate the effectiveness of docusate in facilitating bowel movements. This question directly assesses the expected outcome of the medication. A: "Are you experiencing any burning with urination?" - This question is more relevant to urinary tract infections, not related to docusate use for constipation. C: "Has the medication helped to relieve the nausea?" - Docusate is not typically used to relieve nausea, so this question is not relevant to evaluating its effectiveness. D: "Were you able to sleep soundly the last couple of nights?" - This question is not directly related to the expected outcome of docusate in treating constipation.
Question 4 of 5
Ms. C (bowel resection and colostomy) is receiving epoetin alfa. Which laboratory test will the nurse check to see if the medication should be discontinued?
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin. Epoetin alfa is a medication that stimulates red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication. If hemoglobin levels rise too high, it can lead to complications like blood clots. Checking hemoglobin levels helps determine if the dose of epoetin alfa should be adjusted or discontinued. Summary: B: White cell count - Monitoring white cell count is not directly related to epoetin alfa therapy. C: Potassium level - Monitoring potassium level is important for other medications like diuretics or ACE inhibitors, not specifically for epoetin alfa. D: Blood glucose level - Monitoring blood glucose level is important for diabetic patients but not directly related to epoetin alfa therapy.
Question 5 of 5
Which assessment finding is the most critical and needs to be addressed first?
Correct Answer: A
Rationale: The correct answer is A because tracheal deviation after a pulmonary resection indicates a life-threatening condition like tension pneumothorax. This condition requires immediate intervention to prevent respiratory distress and potential cardiovascular collapse. Tracheal deviation is a red flag sign that signals a medical emergency. Options B, C, and D are important but not as urgent as tracheal deviation. Decreased urinary output in a bladder cancer patient could indicate renal dysfunction, dysrhythmias in a patient with non-Hodgkin lymphoma may need further evaluation, and severe abdominal pain post-bowel resection could signal complications but are not as immediately life-threatening as tracheal deviation.