ATI RN Fundamentals Updated 2023 Exam | Nurselytic

Correct Answer: A

Rationale: The correct answer is A: Identify the impact of the mastectomy on the client's body image. The nurse should first assess the client's emotional state and address her feelings of distress and avoidance. By identifying the impact of the mastectomy on body image, the nurse can provide emotional support and appropriate interventions. This step prioritizes the client's emotional well-being and helps establish trust. Encouraging the client to assist with dressing changes (
B) may not address the underlying emotional distress. Referring the client to a support group (
C) may be beneficial but should come after addressing the immediate emotional needs. Providing a mirror (
D) may worsen the client's distress if she is not ready to confront her incisions.

Correct Answer: C

Rationale: The correct answer is C: "I will wear an N95 respirator mask when caring for the client." This is the correct choice because MRSA can be transmitted through respiratory droplets, and wearing an N95 respirator mask can help prevent the spread of the infection. Removing the gown before gloves (choice
A) is incorrect as it increases the risk of contamination. Asking visitors to wear a mask (choice
B) may be helpful but does not directly address the nurse's protection. Placing the client in a private room (choice
D) is important for isolation but does not focus on the nurse's protection.

Correct Answer: D

Rationale: The correct answer is D: Review the use of an artificial larynx with the client. This is the priority as it directly addresses the client's immediate need for communication after a total laryngectomy. Using an artificial larynx can help the client communicate effectively post-surgery.
Choice A (Schedule a support session for the client) is important but not the priority.

Choices B (Explain the techniques of esophageal speech) and C (Determine the client's reading ability) are not as essential as ensuring immediate communication post-surgery.

Correct Answer: C

Rationale: The correct answer is C: Inform the provider that the client is requesting information about his treatment plan. This is the best course of action as it ensures the client's concerns are communicated directly to the provider, who can then address the client's questions and provide necessary information.
Choice A is incorrect because it delays the client's access to important information by relying on the provider's availability.
Choice B is incorrect as it does not address the client's immediate need for information.
Choice D is incorrect because it assumes the provider's decision-making without involving the client or providing clarity.

Correct Answer: B

Rationale: The correct assessment the nurse should perform first is B: Peripheral pulses. Monitoring peripheral pulses is crucial when a client is restrained to detect any signs of compromised circulation. This assessment takes priority over the other options because impaired circulation can lead to serious complications such as tissue damage or even limb loss. Assessing skin integrity, comfort level, and elimination needs are important tasks but can wait until after ensuring adequate circulation. Checking peripheral pulses is the initial step to ensure the client's safety and prevent potential harm.