ATI Nursing 392-900 Summer Capps Quiz 3 - Adelphi University
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Free ATI Nursing 392-900 Summer Capps Quiz 3 - Adelphi University Questions
Instruct client on use of call bell — Indicated. Given her fall risk, dizziness, and weakness, teaching the client to use the call bell for assistance before getting up promotes safety and helps prevent further falls.
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Contraindicated
Explanation
Correct Answer Is:
Contraindicated
Restraints are not an appropriate first-line fall-prevention measure; they can increase agitation, are a form of restriction requiring a specific order and ongoing justification, and do not address the underlying causes of her fall risk (hypotension, weakness, dizziness).
The nurse educator is teaching a nursing student about Acid Base Balance. Which of the following statements about acid base balance by the nursing student requires further discussion with the nurse?
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"A normal pH is essential to allow for necessary chemical reactions in the body to occur."
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"The respiratory and renal systems are important systems to maintain acid-base balance"
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"pH is the unit that measures acidity and alkalinity."
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"An extremely alkalotic pH cannot cause death, only an extremely acidotic pH can cause death."
Explanation
Correct Answer:
D
Why the other options are incorrect:
A. This statement is accurate, as maintaining a normal pH range is essential for proper enzyme function and cellular chemical reactions to occur, indicating correct understanding.
B. This statement is accurate, as the respiratory system regulates carbon dioxide levels and the renal system regulates bicarbonate and hydrogen ion excretion, both playing key roles in acid-base balance, indicating correct understanding.
C. This statement is accurate, as pH is indeed the scale used to measure the acidity or alkalinity of a solution, indicating correct understanding.
The client tells the nurse that he suffers from heartburn and ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?
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Metabolic alkalosis
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Respiratory acidosis
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Metabolic acidosis
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Respiratory alkalosis
Explanation
Correct Answer:
A
Why the other options are incorrect:
B. Respiratory acidosis results from inadequate ventilation and carbon dioxide retention, not from ingestion of an oral antacid.
C. Metabolic acidosis involves a decrease in bicarbonate or an increase in acid production, which is the opposite effect of bicarbonate-containing antacid ingestion.
D. Respiratory alkalosis results from hyperventilation and excessive carbon dioxide loss, not from a metabolic source such as antacid ingestion.
Which of the following adult clients is at greatest risk for developing heart disease?
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A male with a waist circumference of 35 inches
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A male with a BMI of 34
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A woman with BMI of 24.9
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A female with a waist circumference of 34 inches
Explanation
Correct Answer:
B
Why the other options are incorrect:
A. A waist circumference of 35 inches in a male is within the normal range (increased risk begins at greater than 40 inches), so this does not indicate increased cardiovascular risk.
C. A BMI of 24.9 falls within the normal weight range, indicating this client does not have increased cardiovascular risk related to body weight.
D. A waist circumference of 34 inches in a female is within the normal range (increased risk begins at greater than 35 inches), so this does not indicate increased cardiovascular risk.
The nurse is teaching a newly hired nurse the importance of providing nutrition to patients with an increase in Basal Metabolic Rate (BMR). Which of the following conditions increases Basal Metabolic Rate (BMR)?
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Fever
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Being in an operating room with a cold room temperature
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Sleep
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Being elderly
Explanation
Correct Answer:
A
Why the other options are incorrect:
B. A cold operating room temperature affects the external environment but does not directly cause an increase in the body's basal metabolic rate in the same way an internal physiological process like fever does.
C. Sleep is associated with a decreased metabolic rate, not an increase, as the body's activity and energy expenditure are reduced during rest.
D. Aging is typically associated with a gradual decrease in basal metabolic rate due to loss of muscle mass and changes in body composition, not an increase.
The nurse understands that administering a hypotonic solution to a patient will cause water movement in which of the following directions?
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From transcellular to intracellular space
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From extracellular to intracellular space
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From intracellular to transcellular space
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From intracellular to extracellular space
Explanation
Correct Answer:
(B) From extracellular to intracellular space A hypotonic solution has a lower solute concentration than the cells, causing water to move from the extracellular space into the cells by osmosis in an effort to equalize concentration, which can lead to cellular swelling.
Why the other options are incorrect:
A. Transcellular fluid is a small specialized compartment (such as cerebrospinal or joint fluid) and is not the primary space involved in water shifts from hypotonic solution administration.
C. Water moves into the cells with a hypotonic solution, not out of the cells into the transcellular space.
D. A hypotonic solution causes water to move into the cells, not out of the cells into the extracellular space, which would occur with a hypertonic solution instead.
Administer today's dose of Norvasc/Amlodipine — Contraindicated. The client is already hypotensive at 90/50 mmHg, and administering an additional antihypertensive medication would further lower her blood pressure, increasing her risk for dizziness, falls, and syncope; the provider should be notified before administering this medication.
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Indicated
Explanation
Correct Answer Is:
Indicated
Given her fall risk, dizziness, and weakness, teaching the client to use the call bell for assistance before getting up promotes safety and helps prevent further falls.
Which of the following adult clients is at greatest risk for developing heart disease?
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A male with a waist circumference of 35 inches
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A male with a BMI of 34
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A woman with BMI of 24.9
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A female with a waist circumference of 34 inches
Explanation
Correct Answer:
B
Why the other options are incorrect:
A. A waist circumference of 35 inches in a male is within the normal range (increased risk begins at greater than 40 inches), so this does not indicate increased cardiovascular risk.
C. A BMI of 24.9 falls within the normal weight range, indicating this client does not have increased cardiovascular risk related to body weight.
D. A waist circumference of 34 inches in a female is within the normal range (increased risk begins at greater than 35 inches), so this does not indicate increased cardiovascular risk.
The nurse dons sterile gloves in preparation for performing a sterile procedure. Which of the following can the nurse touch without breaking sterile technique? Select all that apply.
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The inner wrapping of a package of gauze on the middle of the sterile field
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A bottle of Sterile 0.9% Saline next to the sterile field
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One gloved hand with the other gloved hand
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The outer edge of the sterile drape on the sterile field
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An irrigation syringe on the sterile field
Explanation
Correct Answer: (A, C, E) The inner wrapping of a package of gauze on the middle of the sterile field; One gloved hand with the other gloved hand; An irrigation syringe on the sterile field.
Once gloves are donned, the nurse maintains sterility by touching only sterile items. The inner wrapping of a package placed on the middle of the sterile field is considered sterile and can be touched. One sterile gloved hand can touch the other sterile gloved hand without breaking technique. An irrigation syringe placed on the sterile field is considered sterile and can be handled.
Why Other Options are Incorrect:
B. A bottle of sterile saline sitting next to (not on) the sterile field has an unsterile exterior surface, and touching the bottle itself with a sterile glove would contaminate the glove.
D. The outer 1-inch edge of a sterile drape is considered contaminated/unsterile by convention, so touching this edge would break sterile technique.
A student has been assigned to provide hygiene to four clients. Which of the following clients will need special attention to perineal care?
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Middle aged woman with a urinary catheter
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Young adult who had cosmetic surgery
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Teenager who had an appendectomy
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Middle aged man with a nasogastric tube
Explanation
Correct Answer:
(A) Middle aged woman with a urinary catheter Clients with an indwelling urinary catheter require special perineal care to reduce the risk of catheter-associated urinary tract infections by keeping the periurethral area clean and minimizing bacterial contamination around the insertion site.
Why the other options are incorrect:
B. A young adult who had cosmetic surgery unrelated to the perineal area does not require special perineal hygiene attention.
C. A teenager recovering from an appendectomy does not have a specific need for special perineal care unless another complicating factor is present.
D. A middle-aged man with a nasogastric tube requires attention to nasal and oral care, not specifically perineal hygiene.
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