Next Generation Nclex Questions Overview 3.0 ATI Quizlet - Nurselytic

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: A

Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production.

Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.

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: 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: C

Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support.

Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.