ATI RN Fundamentals 2023 | Nurselytic

Correct Answer: A

Rationale:
Correct Answer: A


Rationale: Performing ankle and knee exercises every hour helps prevent muscle atrophy and improve circulation, reducing adverse effects of immobility. This promotes joint mobility and prevents blood clots.


Choice B: Having a partner help change positions every 4 hours may not be frequent enough to prevent complications of immobility.


Choice C: Removing antiembolic stockings while in bed can increase the risk of blood clots as they are meant to promote circulation.


Choice D: Holding breath when rising from a sitting position can lead to dizziness and falls, not addressing the adverse effects of immobility.

Correct Answer: B

Rationale:
Correct Answer: B


Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation. When the client perceives that the education will help address his needs, he will be more motivated to learn and engage in the self-administration process. This belief reinforces the client's understanding of the benefits of learning and empowers him to take control of his health.

Summary of other choices:
A: While the nurse explaining the need for education is important, it may not necessarily increase the client's motivation as much as the client's belief in meeting his needs through education.
C: The nurse's empathy is crucial for building rapport and trust, but it may not directly impact the client's motivation to learn.
D: Seeking family approval can influence behavior, but it may not be the most significant factor in increasing motivation compared to the client's belief in meeting his needs through education.

Correct Answer: A,B,C

Rationale: The correct answer is A, B, and C.
A: Using grab bars when getting in and out of the bathtub enhances safety.
B: Having a fire escape plan is crucial for emergency preparedness.
C: Checking medication expiration dates ensures medication efficacy.
These choices promote home safety. Incorrect choices D and E can be dangerous. Setting the hot water heater to 140 degrees Fahrenheit can cause scalding burns. Applying tape to electrical cords is a fire hazard.

Correct Answer: D

Rationale: The correct answer is D: Administer the client's medications one at a time. This is important for a client with dysphagia to prevent choking or aspiration. Giving medications one at a time ensures the client can swallow each pill safely.

A: Assisting the client into semi-Fowler's position is generally beneficial for swallowing but is not directly related to medication administration for dysphagia.
B: Giving medications between meals may not be ideal for a client with dysphagia as they may need to take medications with food to avoid stomach upset.
C: Encouraging the use of a straw can increase the risk of aspiration for clients with dysphagia due to the potential for liquid to enter the airway.
E, F, G: Irrelevant options.

Correct Answer: D

Rationale: The correct answer is D: Offer to play music in the client's room. Music therapy has been shown to be an effective nonpharmacological intervention for managing pain. Music can help distract the client from pain, promote relaxation, and reduce anxiety. It can also improve the client's mood and overall well-being. Loosening bed linens (
A) may provide comfort but does not directly address pain management. Massaging the sacrum (
B) can potentially worsen the pressure injury. Bright lights (
C) may increase discomfort for a client in pain.
Therefore, offering music therapy is the most appropriate intervention in this scenario.