ATI RN Fundamentals 2023 | Nurselytic

Correct Answer: C

Rationale:
Correct Answer: C. Prepare the client for a central venous line.


Rationale: PN with high osmolarity and high glucose concentration can cause vein irritation and damage peripheral veins.
Therefore, the use of a central venous line is appropriate to minimize the risk of complications like phlebitis and thrombophlebitis.

Incorrect

Choices:
A: Obtaining a random blood glucose daily is important for monitoring blood glucose levels in clients receiving PN, but it does not address the need for a central venous line.
B: Changing the PN infusion bag every 48 hours is a standard practice to prevent contamination but does not address the need for a central venous line.
D: Administering the PN and fat emulsion separately is not necessary as they are often combined in one infusion for convenience and efficiency.

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: D

Rationale: The correct answer is D: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is important to prevent accidental dislodgement of the tracheostomy tube, ensuring proper airway patency. Using a collar with hook-and-loop fasteners allows for secure but adjustable placement, accommodating variations in neck size and minimizing the risk of pressure injuries. A: Wearing clean gloves during inner cannula cleaning is essential for infection control but not directly related to securing the tracheostomy. B: Placing a gauze pad under the flanges helps absorb secretions but does not directly address securing the tracheostomy. C: Cleansing the skin with hydrogen peroxide can be too harsh and irritating; a milder solution like saline is preferred.

Correct Answer: C

Rationale: The correct answer is C: "It's nice having other people cook for me." This statement indicates that the client has adapted to their new situational role because they are acknowledging and appreciating the help and support provided by their adult child in terms of meal preparation. This shows acceptance of their changed circumstances and a willingness to rely on others for assistance, which is a positive sign of adaptation.

Other choices are incorrect:
A: "I'm looking forward to being able to be independent again." This statement indicates a desire for independence, not necessarily adaptation to the new situation.
B: "I've never been the kind of person to ask others for help." This statement suggests resistance to seeking help, which is not indicative of adaptation.
D: "I really don't know what I'm supposed to do all day." This statement indicates confusion and uncertainty, showing a lack of adjustment to the new living arrangement.

Correct Answer: A

Rationale: The correct answer is A: Hold bottles of sterile solution with the label in the palm of the hand. This is correct because it ensures that the nurse maintains sterile technique by preventing contamination of the solution. Holding the bottles with the label in the palm of the hand prevents touching the outside of the bottle, which could introduce contaminants.

Choice B is incorrect because pouring liquids into containers outside the sterile field risks contamination.
Choice C is incorrect as the sterile field should be at the level of the nurse's chest to prevent inadvertent contamination.
Choice D is incorrect because opening the outermost flap of the sterile kit toward the body risks contaminating the contents.