Questions 85

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ATI RN Test Bank

ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions

Extract:


Question 1 of 5

A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: The correct answer is B: Wear your dentures only during meals. This instruction is important for a client with mucositis because wearing dentures continuously can exacerbate irritation and discomfort in the mouth. By removing dentures between meals, the client can allow the oral tissues to rest and promote healing.


Choice A is incorrect because vigorous brushing for 60 seconds can further irritate the mucositis.
Choice C is incorrect as flossing can also cause trauma to the inflamed tissues.
Choice D is incorrect as rinsing with hydrogen peroxide can be too harsh and may worsen the condition. It's important to provide gentle care and minimize irritation to the affected areas in mucositis.

Question 2 of 5

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?

Correct Answer: C

Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.


Choice A is incorrect as it does not actively involve the client in decision-making.
Choice B acknowledges the client's feelings but does not directly engage them in the process.
Choice D focuses on the client's responsibilities but does not promote active participation.

Question 3 of 5

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?

Correct Answer: A

Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system.

Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber.
Choice B is incorrect as lung re-expansion does not directly cause the fluid movement.
Choice C is incorrect as high suction pressure does not cause this specific phenomenon.
Choice D is incorrect as fluid movement does not indicate an air leak.

Question 4 of 5

A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?

Correct Answer: B

Rationale: The correct answer is B: Airborne precautions. Tuberculosis is transmitted through the air via droplet nuclei. Implementing airborne precautions includes wearing an N95 respirator, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (
A) are for all clients, contact precautions (
C) are for direct contact with the client or their environment, and droplet precautions (
D) are for pathogens transmitted through respiratory droplets.
Therefore, implementing airborne precautions is crucial to prevent the spread of tuberculosis.

Question 5 of 5

A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?

Correct Answer: B

Rationale:
Correct Answer: B. Remind the client of the importance of medication adherence.


Rationale: Ensuring medication adherence is crucial for managing AIDS. By reminding the client of this, the nurse advocates for the client's health and well-being. This action promotes the client's self-care and disease management, ultimately empowering the client to take control of their health.

Summary of other choices:
A: Instructing the client to avoid eating raw vegetables is not directly related to client advocacy in the context of AIDS management.
C: Telling the client to avoid large crowds does not directly address the client's ability to continue self-care at home.
D: Initiating a referral to a home health agency may be helpful but does not directly demonstrate client advocacy in this scenario.

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