ATI PN Comprehensive Predictor

The correct answer is : Nonmaleficence.

Explanation:

Nonmaleficence refers to the ethical principle of "do no harm." In this scenario, the nurse questions the medication prescription because it might cause harm to the client due to their advanced age and unstable health status. The nurse is considering the potential risks of administering a treatment that could worsen the client’s condition or cause adverse effects. This action aligns with the principle of nonmaleficence, which emphasizes the nurse's responsibility to prevent harm and minimize potential harm to the client.

Why the other options are incorrect:

Fidelity: Fidelity refers to being loyal, keeping promises, and maintaining trust in the nurse-client relationship. While important in nursing, it is not directly related to questioning a medication prescription that may harm a client. Fidelity is more about honoring commitments, while nonmaleficence involves preventing harm.

Autonomy: Autonomy is the principle that supports a patient's right to make their own decisions regarding their care. In this case, the nurse is questioning the prescription due to concerns about the client's safety, not the client’s ability to make decisions. Therefore, autonomy does not directly apply here

Justice: Justice refers to fairness in the distribution of resources and treatments. While justice is important in healthcare, the nurse's action of questioning the prescription is based on the potential for harm to the client, which is more aligned with nonmaleficence than justice.

Summary:

The nurse's action of questioning the medication prescription due to the client's advanced age and unstable condition is an example of the ethical principle of nonmaleficence, as the nurse is seeking to prevent potential harm to the client.

Correct Answer:  Apply topical analgesic cream to the site 1 hr prior to the procedure.

Explanation:

When preparing an adolescent for a lumbar puncture, one of the most important aspects of the preparation involves minimizing pain and discomfort. Topical analgesic cream, such as lidocaine or EMLA (eutectic mixture of local anesthetics), can be applied to the puncture site 1 hour prior to the procedure to numb the area. This reduces the pain and anxiety associated with the procedure.

The topical analgesic cream numbs the skin and subcutaneous tissues, making the insertion of the needle less painful. It is important to follow the recommended timing for the application of the cream to ensure that it has sufficient time to take effect. Typically, 1 hour before the procedure is optimal for the cream to provide adequate local anesthesia.

Why the other options are incorrect:

Place a cardiac monitor on the adolescent prior to the procedure:

While a cardiac monitor might be used in certain situations, it is not routinely needed for a lumbar puncture. A lumbar puncture is generally a low-risk procedure in adolescents, and placing a cardiac monitor is not a standard practice unless the adolescent has specific cardiac issues or is at risk for complications, which are not indicated in this scenario.

Keep the adolescent in a semi-Fowler’s position for 4 hr following the procedure:

After a lumbar puncture, it is typically recommended to keep the adolescent in a flat or supine position for a certain period (usually 1-4 hours) to reduce the risk of developing a post-lumbar puncture headache. Semi-Fowler’s position (head elevated) is contraindicated immediately following the procedure because it can increase the likelihood of headaches and other complications due to changes in intracranial pressure. The correct position is generally flat to promote healing and reduce the chance of complications.

Restrict the fluids for 2 hr following the procedure:

Fluids should not be restricted after a lumbar puncture unless otherwise indicated for specific clinical reasons (such as a contraindication like heart failure). In fact, after a lumbar puncture, it is typically encouraged to increase fluid intake to help replace lost cerebrospinal fluid (CSF) and reduce the risk of developing a headache. Adequate hydration helps maintain CSF volume and pressure, reducing the risk of complications.

Summary:

The correct action is B. Apply topical analgesic cream to the site 1 hr prior to the procedure. This ensures that the adolescent will experience minimal pain during the lumbar puncture. It is important to apply the cream at the correct time (usually 1 hour prior) to ensure it is effective in numbing the puncture site.

Correct answer: Steadily increasing vital signs.

Explanation:

Steadily increasing vital signs, such as a rise in blood pressure, heart rate, and temperature, are often early indicators of alcohol withdrawal. These increasing vital signs suggest that the client is experiencing withdrawal symptoms that may be escalating. In such cases, the nurse should consider increasing sedation to prevent the progression to more severe withdrawal symptoms, such as seizures or delirium tremens (DTs), which can be life-threatening.

Why the other options are incorrect:

Mild tremors and irritability: Mild tremors and irritability are common symptoms in alcohol withdrawal, particularly in the early stages. These symptoms typically do not require an increase in sedation, as they are often manageable with standard doses and supportive care.

Decreased respirations and disorientation: While these symptoms are concerning and suggest severe withdrawal, they are more indicative of a serious medical emergency such as delirium tremens or respiratory failure. However, this would be an urgent indication to seek immediate medical intervention, rather than simply increasing sedation.

Stomach distress and inability to sleep: These are common but less severe symptoms of alcohol withdrawal. They do not typically require an increase in sedation but can be addressed with supportive care, including medications for nausea or sleep disturbances.

Summary:

Steadily increasing vital signs (option A) are a key indicator that the withdrawal is progressing and may require an adjustment in sedation to manage the symptoms effectively and prevent complications.

The correct answer is : Avoid abrupt changes in posture.

Explanation:

Sublingual nitroglycerin (Nitrostat) is used to relieve angina (chest pain) by dilating blood vessels, which can lower blood pressure. This can cause a drop in blood pressure and may result in dizziness or lightheadedness, especially when moving from a lying or sitting position to standing (postural hypotension). Therefore, it is essential for the client to avoid abrupt changes in posture to prevent falls and complications.

Why the other options are incorrect:

Take the medication five minutes after the pain has started: This is incorrect because the client should take nitroglycerin immediately at the onset of chest pain or discomfort. Waiting five minutes would delay the onset of action and potentially worsen the situation. If the pain persists after the first dose, the client should take another dose after 5 minutes, up to a maximum of 3 doses within 15 minutes, and seek emergency medical attention if pain continues.

Stop taking the medication if a stinging sensation is absent: This is incorrect because a stinging sensation is not necessary for the medication's effectiveness. The lack of a stinging sensation does not indicate that the medication is not working. The primary way to assess effectiveness is whether the chest pain resolves or improves. If the pain does not improve after three doses, the client should seek emergency medical care.

Take the medication on an empty stomach: This is unnecessary. Sublingual nitroglycerin is absorbed rapidly through the mucous membranes under the tongue, and it does not need to be taken on an empty stomach. The key is to place the tablet under the tongue and allow it to dissolve completely without swallowing it or chewing it.

Summary:

The most important caution for clients using sublingual nitroglycerin is to avoid abrupt changes in posture to prevent the risk of orthostatic hypotension. Taking the medication immediately at the onset of pain, not stopping it based on the absence of a stinging sensation, and not requiring an empty stomach are all less critical concerns in comparison.

The correct answer is : Protein.

Explanation:

The client has a history of oliguria, hypertension, and peripheral edema, which are indicative of kidney dysfunction, potentially leading to renal failure. In clients with kidney disease, protein restriction is often recommended to reduce the workload on the kidneys and prevent the accumulation of nitrogenous waste products (such as urea and creatinine), which the kidneys are unable to excrete efficiently. Elevated BUN (blood urea nitrogen), which is 25 mg/dL in this case, further supports that the kidneys may not be filtering waste properly, making protein restriction essential. Protein metabolism generates waste products that can be difficult for compromised kidneys to clear.

Why the other options are incorrect:

Fats.

Fats are not typically restricted for clients with kidney disease unless there is a concern for hyperlipidemia or other comorbid conditions like cardiovascular disease. Fats are generally tolerated in kidney disease unless specifically contraindicated by other factors.

Carbohydrates.

Carbohydrates are not typically restricted in kidney disease unless the client also has issues like diabetes mellitus, which would require carbohydrate control. Otherwise, carbohydrates are usually not the focus of dietary restrictions in renal disease.

Magnesium.

There is no indication from the current lab results that magnesium is elevated, and magnesium restriction is generally only necessary if the client is at risk for hypermagnesemia, which is a concern in severe renal failure. The client's potassium level is normal, suggesting no immediate concern for hyperkalemia or hypermagnesemia at this time.

Summary:

Protein restriction is crucial for clients with kidney disease or compromised kidney function to reduce the accumulation of waste products like urea. Therefore, the client should restrict protein in their diet to help manage their condition and minimize renal workload.

Correct answer: The client will be required to take prescribed medication for a duration of 6-9 months.

Explanation:

For a client newly diagnosed with tuberculosis (TB), one of the most critical aspects of treatment is the long duration of medication required to cure the infection. TB treatment typically lasts for 6-9 months, during which time the client must consistently take prescribed medications, even if they start feeling better before the treatment course is completed. Adherence to the full course of treatment is necessary to prevent relapse and the development of drug-resistant TB. This information should be emphasized in the teaching plan to ensure that the client understands the importance of completing the entire treatment regimen.

Why the other options are incorrect:

During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes: While this is essential advice for preventing transmission, the duration of medication is equally important for ensuring the disease is fully treated and preventing further complications. Therefore, while hygienic precautions are necessary, understanding the treatment duration is also critical.

It is necessary for the client to wear a mask at all times to prevent transmission of the disease: Wearing a mask is not required at all times, and it's more important to focus on the client’s medication adherence. Once the treatment starts taking effect and the client feels better, the risk of transmission decreases significantly. However, consistent medication adherence over the prescribed duration is key to curing the infection.

The family should support the client to help reduce feelings of low self-esteem and isolation: While emotional support is important, it is secondary to the immediate need to ensure the client completes the full treatment regimen. The family’s emotional support can be part of the broader care plan but should not overshadow the critical importance of adhering to the prescribed medication.

Summary:

The most important teaching for a newly diagnosed TB patient is that they will need to take medication for 6-9 months to fully treat the infection. Ensuring the client adheres to this extended course of treatment is essential for curing TB and preventing relapse or drug-resistant strains.

The correct answer is : Perform the Valsalva maneuver (holding breath and bearing down) before doing the catheterization.

Explanation:

In patients with lower motor neuron disorders, performing the Valsalva maneuver before self-catheterization can help to promote bladder emptying. The Valsalva maneuver increases intra-abdominal pressure by holding the breath and bearing down, which may facilitate bladder contraction in those with neurogenic bladders. This can be particularly helpful for individuals who have difficulty initiating bladder emptying due to their condition.

Why the other options are incorrect:

Use a new sterile catheter each time he performs a catheterization: While it's essential to use clean or sterile techniques to prevent infection, some patients with lower motor neuron disorders may use clean (not necessarily sterile) catheters for routine self-catheterization, especially if they are following proper hygiene protocols and disinfecting the catheter between uses. Sterility is not always required for every catheterization, though it’s important to follow healthcare provider recommendations.

Perform the catheterization procedure every 8 hours: The frequency of catheterization should be determined by the individual's needs, bladder capacity, and healthcare provider's instructions. A fixed 8-hour schedule may not be appropriate for everyone. It is more common for individuals to perform catheterizations more frequently, such as every 4 to 6 hours, depending on fluid intake and bladder function.

Limit his fluid intake to reduce the number of times a catheterization is needed: Limiting fluid intake can lead to dehydration and increase the risk of urinary tract infections (UTIs). It’s important to maintain proper hydration, as restricting fluid intake can cause other complications like bladder and kidney issues. The goal is to maintain adequate hydration while performing self-catheterization at regular intervals.

Summary:

The Valsalva maneuver can be beneficial for promoting bladder emptying in patients with lower motor neuron disorders, as it increases abdominal pressure and may help to trigger bladder contraction. The other options are not as suitable for the specific needs of a client with this condition and may not support optimal health outcomes.

Correct answer: The patient's albumin level is 4.0 mg/dL.

Explanation:

Albumin is a key protein produced by the liver, and its level is a critical marker for nutritional status, particularly protein status. A normal albumin level ranges from 3.5 to 5.0 g/dL, and levels below this range often indicate malnutrition, particularly protein deficiency. An albumin level of 4.0 mg/dL is within the normal range and suggests that the patient’s nutritional status has improved, reflecting an adequate response to nutritional support such as total parenteral nutrition (TPN).

Why the other options are incorrect:

The patient eats most of the food served to her: While this indicates an improvement in appetite, it does not directly assess the patient’s nutritional status. The patient may still not be absorbing nutrients properly, especially in cases where TPN is needed, so the improvement in oral intake does not guarantee nutritional status improvement.

The patient has gained 1 pound since admission: A slight weight gain is a positive sign, but weight alone is not the best indicator of nutritional status. Weight can fluctuate due to factors such as fluid retention, so this is not as reliable as specific lab values like albumin.

The patient's hemoglobin is 8.5 g/dL: A hemoglobin level of 8.5 g/dL is low and indicates anemia, which may not be directly related to the patient’s nutritional status at this time. Anemia could be due to various causes such as cancer-related blood loss or chronic disease, but it does not reflect immediate improvement in nutritional status.

Summary:

The best indicator of improvement in the patient’s nutritional status after 4 days of treatment is a normal albumin level (4.0 mg/dL), as it directly reflects the patient’s protein status and overall nutrition.

Correct Answer: Implement a regular toileting schedule

Explanation:

For clients at risk for falls, implementing a regular toileting schedule is an appropriate nursing action. A frequent cause of falls, particularly in hospitalized clients, is the need to get up to use the restroom. Having a regular toileting schedule helps prevent the client from rushing to the bathroom or attempting to get up when they are not fully able to, thereby reducing the risk of falls.

Encourage the client to wear athletic socks when ambulating:

While socks are comfortable, athletic socks typically lack non-slip properties. Encouraging the client to wear socks with rubberized or non-slip soles is a safer choice, as it reduces the risk of slipping while walking or standing.

Place all 4 bed rails in the upright position:

Raising all four side rails is considered a form of restraint and may not be the safest approach for fall prevention. It can cause entrapment risks, lead to the client attempting to climb over the rails, and result in injury. It’s important to use side rails with caution and in compliance with safety guidelines.

Require a family member to remain at the bedside:

While it may be helpful for a family member to stay with the client for emotional support, it is not a long-term solution for fall prevention. The responsibility of preventing falls should primarily be with the healthcare team, including proper environmental modifications, monitoring, and interventions like regular toileting schedules.

Summary:

The most appropriate action for a client at risk for falls is to implement a regular toileting schedule to reduce the need for the client to rush to the bathroom, which can lead to falls. Other fall prevention strategies, such as using non-slip socks and avoiding unnecessary restraints, should also be considered.