ATI RN Fundamentals 2023 II | Nurselytic

Correct Answer: A

Rationale: The correct answer is A: Prepare the client for surgery. In emergency situations where a client is unconscious and requires immediate surgery to prevent harm or save their life, healthcare providers are ethically obligated to act in the client's best interest. This principle, known as beneficence, allows healthcare professionals to provide necessary care in emergency situations without prior consent. By preparing the client for surgery, the nurse ensures the client receives timely and potentially life-saving treatment. Obtaining consent from the surgeon (
B) is not appropriate as the surgeon cannot provide consent on behalf of the client. Contacting the facility's ethics committee (
C) may cause unnecessary delays in providing urgent care. Keeping the client stable until a family member arrives (
D) may jeopardize the client's health and violates the principle of beneficence.

Correct Answer: B

Rationale: The correct answer is B: Cut the old ties after the new ties are secured. This is the correct action because it ensures that the tracheostomy is always secured in place. By securing the new ties first, the nurse prevents accidental dislodgement of the tracheostomy tube during the tie change process. Cutting the old ties after securing the new ties maintains the stability of the tracheostomy and prevents any interruption in the client's breathing.


Choice A is incorrect because allowing space for three fingers under the ties may not provide adequate security for the tracheostomy.
Choice C is incorrect as using a quick-release knot may lead to accidental loosening of the ties.
Choice D is incorrect because extending the client's neck is unnecessary and may cause discomfort.

Correct Answer: D

Rationale: The correct answer is D: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to prevent irritation and damage to the stoma. If the pouch is too tight, it can constrict blood flow and cause injury. Rubbing the peristomal skin dry (
A) can cause irritation, applying the pouch while the skin is damp (
B) can lead to poor adhesion, and changing the pouch every 24 hours (
C) is unnecessary unless leakage or skin irritation occurs.

Correct Answer: C

Rationale: The correct answer is C: Place an activated tuning fork in the middle of the client's forehead. This is the appropriate action for the Weber's test because it helps assess for asymmetrical hearing loss. Placing the tuning fork on the forehead allows sound to be conducted through bone, bypassing the outer and middle ear. If the client hears the sound more in one ear than the other, it indicates conductive hearing loss in the ear that hears it less. Whispering words (
B) and delivering high-pitched sounds (
A) are not part of the Weber's test. Holding the tuning fork against the mastoid process (
D) is part of the Rinne test, not the Weber's test.

Correct Answer: C

Rationale: The correct answer is C: Review the use of an artificial larynx with the client. This is the priority intervention because after a total laryngectomy, the client will need alternative methods for speech, and an artificial larynx is one of the options. It is crucial for the nurse to discuss this with the client prior to the surgery to ensure they understand the use and benefits of this device for communication post-surgery.

A: Scheduling a support session is important but not the priority at this stage.
B: Determining the client's reading ability is not as urgent as ensuring they have a means of communication after the laryngectomy.
D: Explaining esophageal speech is important, but reviewing the artificial larynx is more immediate and essential for communication.