ATI RN Fundamentals 2023 | Nurselytic

Correct Answer: D

Rationale:
Correct Answer: D

Rationale: Cutting the old ties after securing the new ties ensures that the client's airway remains stable throughout the procedure. If the old ties are cut before securing the new ties, there is a risk of accidental decannulation, leading to potential airway compromise. This step-by-step approach prioritizes patient safety and prevents unnecessary risks during the tracheostomy tie change.
Summary:
A: Allowing space for three fingers under the ties is important for proper fit but not the immediate action needed during the tie change.
B: Using a quick-release knot may be helpful for easy removal in emergencies but is not the primary concern during the tie change.
C: Extending the client's neck may help with visualization but is not essential for securing the ties.
D: Cutting the old ties after securing the new ties is the correct action to maintain airway stability.
E, F, G: No information provided.

Correct Answer: C

Rationale: The correct answer is C: "I will leave a light on in my bathroom at night." This statement indicates an understanding of the teaching because older adults with heart failure are at risk for falls due to potential nocturia (frequent need to urinate at night) caused by the diuretic effect of hydrochlorothiazide. Leaving a light on in the bathroom at night can help prevent falls.


Choice A is incorrect because weighing once weekly does not address the immediate safety concern related to falls.
Choice B is unrelated to safety considerations.
Choice D is incorrect as taking a hot bath before bed can potentially increase the risk of falls due to dizziness.

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: A

Rationale: The correct answer is A: Speech-language pathologist. This professional specializes in evaluating and treating swallowing difficulties, known as dysphagia, which is common after a stroke. The speech-language pathologist can assess the client's swallowing function, provide strategies to improve safety during meals, and recommend appropriate diet modifications. The other choices, such as social worker, physical therapist, and occupational therapist, do not have the specific expertise in managing swallowing disorders like a speech-language pathologist does in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Weight. Anthropometric assessment involves measuring the client's body composition, which includes weight. Weight provides important information about the client's nutritional status and overall health. Respiratory rate (
A) is part of a vital signs assessment, not anthropometric assessment. Level of orientation (
C) and current pain level (
D) are important for assessing mental status and pain management, respectively, but they are not part of anthropometric assessment.