Questions 67

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RN ATI Fundamentals of Nursing Questions

Extract:


Question 1 of 5

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

Correct Answer: B

Rationale: 0.45% sodium chloride (
B) is hypotonic helping to dilute excess sodium in hypernatremia. Other solutions may worsen the condition.

Extract:

A nurse is caring for a client.

Nurses' Notes

Day 1:

1300:

Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally, Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow.

Medical History

Day 1:

Diabetes mellitus Hyperlipidemia

Labs

Day 1

Hct 38% (37% to 47%)

Hgb 13 (12 g/dL to 16 g/dL)

WBC 11,500/mm3 (5000 to 10,000/mm3)

Potassium 3.6 mEq/L (3.5 mEq/L to 5 mEq/L)

Pre-albumin level 10 mg/dL (15 to 36 mg/dL)

Albumin: 3.0 g/dL (3.5 to 5 g/dL)

Fingerstick blood glucose, fasting 186 mg/dL (74 to 106 mg/dL)


Question 2 of 5

Select the 5 findings that can cause delayed wound healing.

Correct Answer: B,C,D,E,F

Rationale: Low prealbumin (
B) diabetes (
C) hyperlipidemia (
D) wound infection (E) and decreased perfusion (F) impair healing by affecting nutrition blood flow and immune response.

Choices A and G are not direct causes.

Extract:


Question 3 of 5

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter,the client reports pain in the insertion area. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Removing the catheter and inserting it at a new site addresses pain likely caused by improper placement.

Choices A B and C are less appropriate initial actions.

Question 4 of 5

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)?

Correct Answer: A,C,D

Rationale: Assisting ambulation (
A) feeding (
C) and bathing (
D) are within AP scope.

Choices B and E require nurse expertise.

Question 5 of 5

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer: A

Rationale: Elevating the head no more than 45° (
A) reduces pressure on the sacrum preventing ulcers. Other choices increase risk or are ineffective.

Similar Questions

A nurse administers an incorrect medication to a client. Following an assessment of the client,the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?
A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable?
A nurse is caring for several clients who are at various developmental stages. The nurse should explain that,according to Erikson acceptance of death is a primary task of which of the following stages of psychosocial development?
A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider,who tells the nurse to restrain the client if necessary to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

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