ATI RN Fundamentals 2023 II | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Assist the client with a bowel cleansing. Prior to an intravenous pyelogram, it is important to ensure the client has a clear bowel to improve visualization of the urinary tract. This is typically achieved through bowel cleansing to prevent any fecal material from obstructing the view of the kidneys and bladder during the procedure.

Incorrect choices:
A: Ensuring the client is free of metal objects is important for MRI scans, not intravenous pyelograms.
B: Monitoring for pain in the suprapubic region is not a standard preparation for an intravenous pyelogram.
D: Administering oral contrast is not typically required for an intravenous pyelogram, as the contrast material is injected intravenously for this procedure.

Correct Answer: B

Rationale: The correct answer is B: Cut the old ties after the new ties are secured. This is the correct action because it ensures that the tracheostomy is always secured in place. By securing the new ties first, the nurse prevents accidental dislodgement of the tracheostomy tube during the tie change process. Cutting the old ties after securing the new ties maintains the stability of the tracheostomy and prevents any interruption in the client's breathing.


Choice A is incorrect because allowing space for three fingers under the ties may not provide adequate security for the tracheostomy.
Choice C is incorrect as using a quick-release knot may lead to accidental loosening of the ties.
Choice D is incorrect because extending the client's neck is unnecessary and may cause discomfort.

Correct Answer: A,B,D,E

Rationale: The correct actions for the nurse to take in this scenario are A, B, D, and E. A diuretic can help manage fluid overload, oxygen can help alleviate hypoxia, stopping the transfusion is crucial to prevent further complications, and placing the client in high-Fowler's position can improve oxygenation. Administering epinephrine is not indicated as it is not a standard treatment for these symptoms. Obtaining a prescription for a diuretic is more urgent than administering one as the client is already showing signs of fluid overload. Administering epinephrine without assessing the client's condition further could worsen their symptoms.

Correct Answer: D

Rationale: The correct answer is D. This statement indicates that the client has adapted to their new situational role because it shows acceptance and appreciation of the assistance provided by their adult child. By stating, "It's nice having other people cook for me," the client acknowledges and values the support and care being offered, demonstrating a positive adjustment to their changed living situation.

A: This statement suggests a desire for independence, which may indicate the client is not fully adapted to relying on their adult child.
B: This statement indicates confusion and uncertainty, signaling a lack of adjustment to their new living arrangement.
C: This statement reflects a reluctance to ask for help, which may hinder the client's ability to adapt and receive necessary support.

Correct Answer: B

Rationale: The correct answer is B: Activate the facility's fire alarm. This is the next action the nurse should take after ensuring the client's safety. Activating the fire alarm alerts other staff members and emergency services, allowing for a quicker and more coordinated response to the fire. Placing wet towels along the base of the door (choice
A) may help prevent smoke from entering the room but does not address the larger issue of alerting others to the fire. Directing a fire extinguisher at the fire (choice
C) should only be done if the nurse is trained to do so and it is safe. Turning off any electrical equipment (choice
D) may be necessary to prevent further hazards but does not take precedence over alerting others to the fire.