ATI PN Fundamentals 2023

Extract:

Question 1 of 5

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Order the Items

Source Container

Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.

Unlock and remove the inner cannula.

Scrub the inside and outside of the inner cannula with a small brush.

Cleanse the stoma site with 0.9% sodium chloride solution.

Wipe the inside of the inner cannula with a folded pipe cleaner.

Correct Answer: A,B,C,E,D

Rationale: A: Prepare solution. B: Remove cannula. C: Scrub cannula. E: Wipe cannula. D: Cleanse stoma ensures sterile technique.

Question 2 of 5

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

A. Ask the client to state their room number. B. Have the client state their phone number. C. Review the client's photograph in the medical record. D. Request an assistive personnel to identify the client.

Correct Answer: C

Rationale: A photograph in the record is a reliable identifier for a client with dementia.

Question 3 of 5

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

A. I'm glad to have the opportunity to choose what kind of care I receive while I still can. B. If I want life support, I'll need to sign a separate consent form first. C. I can't change my mind about the care I will receive once I sign my living will. D. Once I fill out my living will, there will be a 1-month delay before it is legally binding.

Correct Answer: A

Rationale: Advance directives allow clients to specify care preferences, reflecting autonomy.

Question 4 of 5

A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?

A. Tuna fish B. Clam chowder C. Cheese D. Chicken

Correct Answer: C

Rationale: Cheese fits a lacto-vegetarian diet, which includes dairy but excludes meat and fish.

Question 5 of 5

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?

A. Recheck the client's SaO2 level after having the client cough and clear their throat. B. Notify the charge nurse of the client's condition. C. Review the client's most recent SaO2 level in the medical record. D. Check the client's medical records to see which medications were recently admitted.

Correct Answer: A

Rationale: Rechecking SpO2 after clearing the airway rules out temporary obstruction as the cause.

ATI PN Fundamentals 2023 | Nurselytic

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