ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
Correct Answer: C
Rationale: Changing the dressing four times per day is excessive and not typically recommended. Most guidelines suggest changing the dressing once a day or as needed if it becomes soiled or wet. Over-frequent dressing changes can disrupt the healing process and increase the risk of infection. Applying tincture of benzoin prior to removing the dressing is not a standard practice for wound care. Tincture of benzoin is usually used to increase the adhesion of bandages or tapes, not for removing dressings. Using it inappropriately could cause skin irritation or damage. Cleaning from the incision to the surrounding skin is the correct method. This technique helps prevent the spread of bacteria from the surrounding skin into the incision site, reducing the risk of infection. Always use a sterile solution and clean gauze for this process. Using sterile gloves when removing the old dressing is important to maintain a sterile environment and prevent infection. However, this is a general practice and not specific to the wound care instructions provided in the question.
Question 2 of 5
A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
Correct Answer: A
Rationale: Dyspnea post-hip arthroplasty could indicate a pulmonary embolism, a life-threatening emergency requiring immediate assessment. UTI with fever, moderate pain, and stable pneumonia are less urgent.
Question 3 of 5
A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, 'I should start planning the trip that we want to take.' Which of the following ego-defense mechanisms is the client expressing?
Correct Answer: B
Rationale: Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner's condition. Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client's statement about planning a trip despite their partner's terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner's impending death. Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client's statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality. Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner's condition.
Question 4 of 5
A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?
Correct Answer: B
Rationale: Garlic is not typically used for menopausal symptoms. Common herbal supplements for menopause include black cohosh, red clover, and evening primrose oil. These herbs are known to help alleviate symptoms such as hot flashes and night sweats. Garlic, on the other hand, is more commonly associated with cardiovascular benefits, such as lowering blood pressure and cholesterol levels. Ginger is well-known for its effectiveness in treating nausea and motion sickness. Studies have shown that ginger can help reduce symptoms of motion sickness, such as dizziness, vomiting, and cold sweats. It works by stabilizing digestive function and maintaining consistent blood pressure, which helps alleviate nausea.
Therefore, using ginger for car sickness is a correct and effective use of the supplement. Ginkgo biloba is not typically used for headaches. It is more commonly used to improve cognitive function and circulation. While some studies suggest that ginkgo biloba may help reduce the frequency and severity of migraines due to its antioxidant properties, it is not a primary treatment for headaches. Other supplements, such as feverfew and butterbur, are more commonly recommended for headache relief. Echinacea is primarily used to boost the immune system and help fight infections, such as the common cold. There is no substantial evidence to support the use of echinacea for controlling cholesterol levels. For cholesterol management, supplements like omega-3 fatty acids, plant sterols, and soluble fiber are more effective.
Question 5 of 5
A nurse is planning an educational program for older adult clients. Which of the following techniques should the nurse use when teaching?
Correct Answer: B
Rationale: Limiting the session to 1 hour is a practical approach when teaching older adults. Research indicates that older adults may have shorter attention spans and may become fatigued more quickly than younger individuals. However, providing a distraction-free environment is more critical for effective learning. Providing an environment with minimal distractions is crucial for effective learning, especially for older adults. Distractions such as noise, poor lighting, and uncomfortable seating can hinder concentration and reduce the effectiveness of the educational program. By creating a calm and focused environment, the nurse can help older adults concentrate better on the material being taught. Presenting the information at a 10th-grade reading level may be too complex for some older adults with varying literacy levels. A lower reading level (e.g., 6th-8th grade) is often recommended for health education to ensure accessibility. Using brightly colored paper can enhance visibility and engagement, especially for those with visual impairments, but it’s less impactful than minimizing distractions for overall comprehension.