ATI PN Fundamentals 2023 Exam 4

Extract:

Question 1 of 5

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

A. Review the client's photograph in the medical record.B. Request an assistive personnel to identify the client.C. Ask the client to state their room number.D. Have the client state their phone number.

Correct Answer: A

Rationale: A photograph ensures accurate identification, critical for a client with dementia unable to self-identify.

Question 2 of 5

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A. Assess the pain level of a client who has received acetaminophen.B. Check a client's peripheral IV site for redness or swelling.C. Measure the intake and output of a client who has received furosemide.D. Reinforce teaching with a client about crutch-gait walking.

Correct Answer: C

Rationale: Measuring intake and output is within the APâ€™s scope and appropriate for delegation.

Question 3 of 5

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A. The stoma is draining a small amount of liquid stool.B. The stoma protrudes slightly from the abdomen.C. The stoma appears dark in color.D. The stoma bleeds lightly when touched.

Correct Answer: C

Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.

Question 4 of 5

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?

A. Document the refusal in the client's medical record.B. Return the medication to the medication cabinet.C. Inform the client of the potential consequences of their refusal.D. Notify the provider of the client's refusal.

Correct Answer: C

Rationale: Informing about consequences first respects autonomy and may encourage compliance.

Question 5 of 5

A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

A. Apply suction while inserting the catheter.B. Apply intermittent suction for up to 30 seconds.C. Preoxygenate the client prior to suctioning.D. Instruct the client to swallow during catheter insertion.

Correct Answer: C

Rationale: Preoxygenation prevents hypoxia during suctioning, enhancing safety.

ATI PN Fundamentals 2023 Exam 4 | Nurselytic

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