ATI ASN Fundamentals NSG 1550 Exam 2
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Free ATI ASN Fundamentals NSG 1550 Exam 2 Questions
A nurse is caring for several clients on a medical-surgical unit. Which of the following clients is at the highest risk for developing constipation?
- A client on a low-fat diet following gallbladder removal 6 months ago.
- A client taking a stool softener daily and walking 30 minutes each evening.
- A client who eats three balanced meals per day and drinks 2,000 mL of fluid daily.
- A client recovering from a cerebrovascular accident (stroke) who requires assistance with ambulation.
Explanation
Correct Answer: D) A client recovering from a cerebrovascular accident (stroke) who requires assistance with ambulation.
Clients who have had a stroke often experience decreased mobility, muscle weakness, and possible neurological impairment affecting bowel function. Reduced physical activity slows intestinal motility, which increases the risk of constipation.
In addition, stroke clients may have difficulty with adequate fluid intake, dietary changes, or medications that further contribute to constipation. Limited mobility is one of the most significant risk factors for constipation in hospitalized patients, making this client the highest risk among the options.
A nurse is preparing to discharge an elderly client who lives alone following hospitalization for pneumonia. The client takes multiple medications for chronic conditions, reports having a limited income, and expresses concern about preparing meals. Which of the following actions should the nurse take to best promote the client's nutritional status after discharge?
- Encourage the client to fast intermittently to improve metabolic health and appetite.
- Instruct the client to avoid high-fat and high-calorie foods to prevent weight gain.
- Refer the client to a social worker to discuss access to community meal support services.
- Recommend the client shop for groceries in bulk to reduce overall food expenses.
Explanation
Correct Answer: C) Refer the client to a social worker to discuss access to community meal support services.
Given the client's limited income and difficulty preparing meals, connecting the client with community resources, such as meal support services, ensures that they have access to nutritious food without the burden of meal preparation. A social worker can help assess the client's eligibility for programs that provide affordable or free meals, which is essential for promoting long-term nutritional health.
Other options, like encouraging fasting or avoiding certain foods (Options A and B), are not practical or beneficial in addressing the client's current challenges. Additionally, while shopping in bulk (Option D) could reduce costs, it may not be the most immediate or effective solution for someone with limited resources or difficulty preparing meals.
A nurse is caring for a client who has a history of falls. Which of the following actions should the nurse take to reduce the risk of falls?
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Place clients at risk for falls away from the nurses’ station.
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Complete a fall-risk assessment for each client at admission.
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Avoid responding to call lights.
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Keep 4 side rails up at all times.
Explanation
Correct Answer:B) Complete a fall-risk assessment for each client at admission.
A fall-risk assessment is a systematic evaluation used to identify individuals who are at an increased risk for falls. It helps nurses and healthcare providers assess various factors, such as the patient's medical history, mobility, cognitive status, and environmental factors, that could contribute to an increased risk of falling.
By completing a fall-risk assessment upon admission, the nurse can identify specific risks early on and take appropriate action to prevent falls. This may include interventions like ensuring proper lighting, securing personal items, ensuring adequate support during movement, and providing the necessary equipment such as walking aids.
Identifying patients at high risk for falls helps prioritize care and allows for targeted prevention strategies. Additionally, regular reassessments during hospitalization are crucial, as patient conditions can change, thus providing the nurse with the information needed to modify or enhance care plans over time. This practice ensures safety, minimizes the risk of falls, and improves overall patient outcomes.
A nurse is caring for a client who has a new ileostomy. Which of the following findings should the nurse expect?
- The stoma will have two openings, one for stool and one for mucus drainage.
- The output will be liquid and continuous.
- The stool output will be infrequent and similar to normal bowel movements.
- The stoma is located in the sigmoid colon and will drain formed stool.
Explanation
Correct Answer: B) The output will be liquid and continuous.
An ileostomy is created by bringing the ileum (the last part of the small intestine) to the surface of the abdomen. As a result, the stool from an ileostomy will typically be liquid and continuous due to the incomplete absorption of water in the small intestine. The output will generally be more fluid compared to a colostomy, which typically produces more solid stool as it is closer to the colon. Therefore, liquid and continuous output is expected with a new ileostomy.
A nurse is teaching a client newly diagnosed with diabetes how to perform blood glucose monitoring at home. Which of the following statements by the client indicates correct understanding?
- "I will clean the site with alcohol and let it dry before puncturing."
- "I should use the first drop of blood that appears for testing."
- "I'll puncture the center of my fingertip for the best sample."
- "I should milk my finger to get enough blood if the flow is slow."
Explanation
Correct Answer: B) "I should use the first drop of blood that appears for testing."
The first drop of blood is the best sample because it is the most accurate and cleanest, without contamination from the puncture site. It is essential to avoid using the second drop, as it can be diluted with tissue fluid, which may cause inaccurate readings.
A nurse is preparing a client for a computed tomography (CT) scan of the abdomen using IV contrast. Which of the following actions should the nurse take before the scan? Select all that apply.
- Administer an oral barium preparation before the scan.
- Inform the client they may feel a warm sensation or metallic taste during contrast injection.
- Verify the client’s allergy history, especially for iodine or shellfish.
- Keep the client NPO for 4 hours prior to the procedure.
- Ensure renal function is assessed before administering contrast.
Explanation
Correct Answer: B, C, D, E
- B) Inform the client they may feel a warm sensation or metallic taste during contrast injection: This is an important part of patient education. It prepares the client for common sensations during the CT scan procedure, ensuring they are not alarmed.
- C) Verify the client’s allergy history, especially for iodine or shellfish: This is critical as patients who are allergic to iodine or shellfish are at an increased risk for allergic reactions to contrast media, which often contains iodine.
- D) Keep the client NPO for 4 hours prior to the procedure: Keeping the client NPO (nothing by mouth) before the procedure minimizes the risk of aspiration and ensures that the stomach is empty for accurate imaging.
- E) Ensure renal function is assessed before administering contrast: Kidney function is crucial when administering IV contrast because contrast agents are excreted through the kidneys. Renal impairment can increase the risk of contrast-induced nephropathy.
A nurse is teaching a male client how to apply and care for a condom catheter at home. Which of the following statements indicates FURTHER teaching is needed?
- "I’ll make sure the tubing is not twisted or looped below the drainage bag."
- "I will check for swelling or redness each time I change it."
- "I will wash and dry my penis before applying the new catheter."
- "I’ll pull the catheter tight so it won’t leak."
Explanation
Correct Answer: D) "I’ll pull the catheter tight so it won’t leak."
When applying a condom catheter, it is important not to pull it too tight. Pulling the catheter tightly can cause discomfort, restrict blood flow, and increase the risk of skin breakdown or irritation. The catheter should be applied snugly but not excessively tight to ensure comfort and proper drainage.
Statements A, B, and C reflect appropriate instructions for using a condom catheter. Ensuring the tubing is not twisted (A), checking for signs of infection (B), and properly cleaning the area before application (C) are all essential steps in maintaining skin integrity and preventing complications.
5 g=0.5×2 mL=1 mL0.5 \text{ g} = 0.5 \times 2 \text{ mL} = 1 \text{ mL}0.5 g=0.5×2 mL=1 mL
Thus, the nurse should administer 1 mL per dose.
Based on the most frequent cause of death in adolescents, which preventive measure would the nurse most want to teach?
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Water safety
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Home safety
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Motor vehicle safety
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Firearm safety
Explanation
Correct Answer: C) Motor vehicle safety
Motor vehicle accidents are the leading cause of death in adolescents. Teaching adolescents about motor vehicle safety, including wearing seat belts, avoiding distractions while driving, and not driving under the influence of alcohol or drugs, is critical in preventing these fatalities. This education helps reduce the risk of accidents and enhances awareness of safe driving practices
The provider prescribes ibuprofen 600 mg PO every 6 hours PRN for pain. Available: ibuprofen 200 mg per tablet. How many tablets should the nurse administer for one dose?
Explanation
Correct Answer: 3 tablets
To calculate how many tablets the nurse should administer, divide the prescribed dose (600 mg) by the amount of ibuprofen in each tablet (200 mg).
- 600 mg ÷ 200 mg = 3 tablets.
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