Next Generation Nclex Questions Overview 3.0 ATI Quizlet - Nurselytic

Correct Answer: A

Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice
C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice
B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice
D) does not adhere to the recommended frequency of every 2 hours.

Correct Answer: C

Rationale: In an obstetrical emergency, the immediate action the nurse should take after the baby delivers is to suction the baby's mouth and nose to ensure the infant can breathe properly. This helps clear any potential obstructions and establish a clear airway. Cutting the umbilical cord (
Choice
B) and wrapping the baby in a clean blanket (
Choice
D) are important steps but should come after ensuring the baby's airway is clear. Placing extra padding under the mother (
Choice
A) is not a priority in this emergency situation as the focus should be on the baby's immediate needs for breathing and airway clearance.

Correct Answer: B

Rationale: Pain tolerance in elderly clients with cancer is likely to decrease due to factors such as diminished adaptative capacity, increased physical discomfort, and the psychological impact of the disease. Cancer is known to cause various physical and emotional stressors that can lower the pain threshold, leading to a decrease in pain tolerance.

Choices A, C, and D are incorrect because cancer and its associated effects typically result in a decrease in pain tolerance rather than remaining constant, increasing, or having no impact.

Correct Answer: D

Rationale: Huntington's chorea is a neurological disorder characterized by writhing, twisting movements of the face and limbs, known as chorea. Epilepsy is characterized by seizures, not writhing, twisting movements. Parkinson's disease presents with tremors, rigidity, and bradykinesia, not writhing, twisting movements. Multiple sclerosis affects the central nervous system but does not typically involve writhing, twisting movements.
Therefore, the correct answer is Huntington's chorea as it specifically manifests with these characteristic movements.

Correct Answer: A

Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.