ATI PN Fundamentals Updated 2023

Extract:

Question 1 of 5

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

A. I listen to my favorite music to take my mind off the pain. B. I learn to notice the sensation of muscle tension. C. I use focused breathing to control my pain. D. I think about my grandfather's farm to reduce pain.

Correct Answer: D

Rationale: Thinking about a pleasant place like a farm is guided imagery, altering pain perception through imagination. Music, tension awareness, and breathing are distraction, mindfulness, and relaxation, respectively.

Question 2 of 5

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A. Clean around the urinary meatus from front to back. B. Separate the labia with the nondominant hand. C. Insert the catheter into the urethral meatus. D. Secure the catheter to the client's thigh. E. Inflate the catheter balloon.

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

Rationale: The correct order is: Clean the meatus (
A), separate labia (
B), insert catheter (
C), inflate balloon (E), secure to thigh (
D). This sequence minimizes infection risk and ensures proper placement.

Question 3 of 5

A nurse is preparing to administer sucralfate 80 mg/kg/day divided into four doses per day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/10 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Your Answer:

Correct Answer: 7 mL

Rationale: Calculate: 80 mg/kg/day Ã— 35 kg = 2800 mg/day; 2800 mg Ã· 4 doses = 700 mg/dose; 1 g = 1000 mg, so 700 mg = 0.7 g; 1 g/10 mL = 0.7 g/X mL, X = 7 mL.
Answer: 7 mL.

Question 4 of 5

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard?

A. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks. B. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site. C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds. D. An assistive personnel raises all four side rails of a client's bed before leaving the room.

Correct Answer: D

Rationale: Raising all four side rails of a client's bed is a safety hazard because it increases the risk of injury if the client tries to climb over them. It also restricts the client's mobility and may cause feelings of isolation and imprisonment. It is a violation of the client's rights and dignity. A weight-sensitive sensor mat is a safety measure to prevent falls, a buzzing sensation from a TENS unit is expected, and a capillary refill of less than 2 seconds indicates good perfusion.

Question 5 of 5

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

A. Witness the client's signature on a consent form. B. Obtain verbal consent from the client. C. Have another nurse co-sign the client's consent. D. Check the medical record for the client's signature on a previous consent form.

Correct Answer: B

Rationale: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it. Written consent is not required for this routine procedure, co-signing is unnecessary, and previous consent does not apply to the current procedure.

ATI PN Fundamentals Updated 2023 | Nurselytic

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