ATI Custom Fundamentals Final Exam Fall 2023 | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Infection. A cool and taut catheter site in a client receiving IV therapy may indicate an infection. Infections can cause localized inflammation and result in the catheter site feeling cool and taut. The nurse should assess for other signs of infection such as redness, pain, swelling, and warmth at the site. IV fluid leaking would more likely indicate infiltration (choice
D) rather than infection. Phlebitis (choice
B) refers to inflammation of the vein, typically presenting with redness and tenderness along the vein. Circulatory overload (choice E) would manifest with symptoms such as shortness of breath and increased blood pressure, not a cool and taut catheter site.

Correct Answer: A

Rationale: The correct answer is A: Using silence. Silence in therapeutic communication allows the patient to collect their thoughts and express themselves without feeling rushed. It promotes reflection and deeper understanding. Offering sympathy (
B) may convey judgment or bias. Offering personal opinions (
C) can hinder open dialogue and may not be relevant to the patient's needs. Providing passive responses (
D) lacks engagement and may not address the patient's concerns effectively. In summary, using silence promotes active listening and allows for a more meaningful exchange in therapeutic communication.

Correct Answer: A

Rationale: The correct answer is A. By contacting the provider and completing an incident report, the nurse is demonstrating accountability, which is a key component of professionalism. Accountability involves taking responsibility for one's actions, acknowledging mistakes, and taking steps to rectify them. In this scenario, the nurse is taking proactive measures to address the error and prevent harm to the client.

Summary of other choices:
B: Accountability - This is the correct answer.
C: Confidence - Confidence is not the primary component being demonstrated in this scenario.
D: Fairness - Fairness is not directly related to the nurse's actions in administering the wrong medication.
E: Advocacy - While advocacy is important in nursing, it is not the primary focus in this situation where accountability is key.

Correct Answer: C

Rationale: Rationale for Correct Answer C: The nurse should secure the restraints using a quick-release tie to ensure the client's safety in case of an emergency. Quick-release ties allow for easy and rapid removal of restraints when necessary, preventing any delays in providing urgent care. This practice also aligns with patient rights and safety guidelines, promoting ethical and appropriate restraint use.

Summary of Incorrect

Choices:
A: Anticipating removing restraints every 4 hr is a general guideline for restraints, but securing them with a quick-release tie is more crucial.
B: Ensuring four fingers fit under restraints is important for proper fit but does not address the safety aspect provided by a quick-release tie.
D: Securing restraints to the lowest bar of the side rail may not facilitate quick release in emergencies and could potentially hinder easy removal.

Correct Answer: D

Rationale: The correct answer is D: Obtaining a blood pressure for a client who is to be discharged later in the day. The nurse can delegate this task to an assistive personnel (AP) as it is within their scope of practice and does not require critical thinking or decision-making skills. The AP can be trained to accurately measure blood pressure, ensuring the client's safety and well-being. Tasks A, B, and C involve more specialized knowledge and skills that only a nurse should perform.
Choice A requires specific training in tracheostomy care, choice B involves assessing a client post-surgery which may require critical thinking, and choice C involves teaching a preoperative client about using an incentive spirometer, which requires educational expertise.
Therefore, choices A, B, and C are not appropriate tasks for delegation to an AP.