ATI RN Fundamentals 2023 | Nurselytic

Correct Answer: D

Rationale: The correct answer is D: Administer the client's medications one at a time. This is important for a client with dysphagia to prevent choking or aspiration. Giving medications one at a time ensures the client can swallow each pill safely.

A: Assisting the client into semi-Fowler's position is generally beneficial for swallowing but is not directly related to medication administration for dysphagia.
B: Giving medications between meals may not be ideal for a client with dysphagia as they may need to take medications with food to avoid stomach upset.
C: Encouraging the use of a straw can increase the risk of aspiration for clients with dysphagia due to the potential for liquid to enter the airway.
E, F, G: Irrelevant options.

Correct Answer: B,D,E,F

Rationale: The correct answer is B, D, E, and F. Monitoring blood pressure (
B) is crucial to assess for potential respiratory distress. Urticaria (
D) indicates a possible allergic reaction requiring immediate attention. Swollen tongue (E) can be a sign of angioedema, a severe allergic reaction affecting the airway. Bilateral breath sounds with wheezing (F) suggest respiratory compromise requiring prompt intervention. Heart rate (
A) and temperature (
C) are important but not as urgent in this scenario.

Correct Answer: A

Rationale: The correct answer is A: "The scale measures six elements." The Braden scale indeed assesses six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This response shows an understanding of the scale's components.
Choice B is incorrect because the client's age is not a factor in the Braden scale assessment.
Choice C is incorrect as a higher score on the Braden scale indicates a lower pressure injury risk.
Choice D is incorrect because each element on the Braden scale has a range from one to four points, not one to five.

Correct Answer: A,C

Rationale: The correct answers are A and C. Option A is important as adjusting oxygen flow rate can help ease breathing, ensuring optimal oxygen delivery. Option C advises storing the oxygen cylinder wrench with the tank for easy access in case of emergencies. These two pieces of information are crucial for maintaining proper oxygen therapy and ensuring safety.

Options B, E, F, and G are incorrect. Option B states a specific duration for antibiotic therapy, which may vary depending on the type of infection. Option E relates to steroid medication administration timing, which can vary based on the specific medication and condition. Option F provides general advice on antibiotic administration but may not apply to all antibiotics. Option G implies a specific tapering schedule for steroids, which should be individualized based on the patient's condition and response.

Correct Answer: C

Rationale: The correct answer is C: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is important to prevent any damage to the abdominal organs near the umbilicus. Injecting heparin too close to the umbilicus can lead to injury or bleeding.

Choice A is incorrect because an 18-gauge, 1-inch needle is too large for subcutaneous injections like heparin administration.
Choice B is incorrect as massaging the injection site after withdrawing the needle can increase the risk of bruising or bleeding.
Choice D is incorrect as expelling air bubbles before injecting medication is essential for intravenous injections, not subcutaneous injections like heparin.