ATI RN Fundamentals 2023 II | Nurselytic

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: D

Rationale: The correct answer is D: Roll the client as one unit in a smooth, continuous motion. This is the correct action to prevent any unnecessary strain or injury to the client's lower back. Rolling the client as one unit maintains the alignment of the spine and minimizes twisting movements that could exacerbate the injury. Placing the client's arms at their sides (
A) is not as crucial as maintaining proper spinal alignment. Placing the client on the side of the bed nearest the direction they will be turned (
B) does not ensure proper alignment during repositioning. Flexing the client's knees (
C) may not be necessary if the client can be rolled smoothly. Overall, rolling the client as one unit is the safest and most effective method for repositioning a client with a lower back injury.

Correct Answer: D

Rationale: The correct answer is D: Client advocate. The nurse manager is functioning in the role of a client advocate by ensuring the safety of the client during the straight catheterization procedure. Advocacy involves protecting the client's rights, promoting their well-being, and ensuring they receive safe and appropriate care. The other choices are incorrect because:
A) Case manager focuses on coordinating care and resources for the client,
B) Client educator involves providing information and teaching the client about their care, and
C) Client care provider refers to directly providing hands-on care to the client, which is not the primary role of the nurse manager in this scenario.

Correct Answer: D

Rationale: The correct answer is D: "I will repeat these movements 3 to 5 times." This is the best choice because passive range-of-motion exercises should be repeated multiple times to prevent joint stiffness and contractures. Moving joints quickly (
A) may cause injury. Performing the exercises only once per day (
B) may not be sufficient for maintaining joint mobility. Moving joints to the point of mild pain (
C) can lead to discomfort and potential harm.
Therefore, option D is the most appropriate for promoting joint mobility and preventing complications.

Correct Answer: B,C,D,E

Rationale: The correct findings that require immediate follow-up are breath sounds, blood pressure, heart rate, and swollen tongue. Breath sounds are essential to assess respiratory status. Blood pressure and heart rate indicate cardiovascular function. A swollen tongue could indicate an allergic reaction or airway compromise. Temperature, urticaria, and an absent option do not necessarily require immediate follow-up as they may not directly impact the client's immediate health status.