ATI PN Comprehensive Predictor

The correct answer is: Suggest fluid intake of at least 2 L per day.

Explanation:

Constipation after colostomy surgery can occur due to changes in bowel function and dietary adjustments following the procedure. Adequate fluid intake is crucial for preventing constipation because it helps soften the stool and facilitates bowel movements. A minimum of 2 liters of fluid per day is recommended to ensure proper hydration and support healthy digestion. Fluids, especially water, help in maintaining the proper consistency of stool and assist in promoting regular bowel movements.

Why the other options are wrong:

Instruct the patient to keep a record of food intake.

While keeping track of food intake can be beneficial for monitoring dietary habits and identifying specific triggers for constipation, it is not the primary intervention for relieving constipation. Fluid intake and dietary adjustments (e.g., increasing fiber) are more directly relevant to addressing the patient's constipation.

Instruct the patient to avoid prune or apple juice.

This suggestion is incorrect because prune and apple juice are both natural remedies for constipation. Prune juice, in particular, is known for its ability to help relieve constipation due to its high fiber content and sorbitol, which has a laxative effect. Avoiding these juices would not be appropriate unless specifically contraindicated by a healthcare provider, as they can aid in bowel regularity.

Assist the patient regarding the correct diet or to minimize food intake.

While it's important to assist the patient with dietary choices, suggesting that the patient minimize food intake is not advisable for constipation. Rather, a diet rich in fiber, including fruits, vegetables, and whole grains, is more beneficial. Inadequate food intake could lead to further complications such as malnutrition or insufficient fiber, which could worsen constipation.

Summary:

For a patient experiencing constipation after colostomy surgery, the most effective intervention is to suggest a fluid intake of at least 2 liters per day to maintain hydration and promote bowel regularity. While tracking food intake can be helpful for monitoring diet, it's not as directly relevant to managing constipation. Prune and apple juices can actually aid in relieving constipation, and minimizing food intake is not an appropriate approach for this issue.

Correct Answer: Assess the client's gait for steadiness.

Explanation:

For a client with dementia who is wandering, the priority is ensuring their safety while they are walking. Assessing the client's gait for steadiness is essential to identify any risk of falls or instability. By determining whether the client is at risk for falls, the nurse can implement strategies to prevent injury, such as using appropriate assistive devices, ensuring the environment is free of hazards, or providing additional supervision if needed.

Why the other options are incorrect:

Administer PRN haloperidol (Haldol) to decrease the need to walk:

While antipsychotic medications like haloperidol are sometimes used in managing agitation or aggressive behaviors in dementia, they are not appropriate for simply preventing wandering. The use of antipsychotics for wandering or non-aggressive behavior is controversial due to potential side effects and is generally not recommended unless the wandering is part of severe agitation or aggression.

Restrain the client in a geriatric chair:

Restraint use is generally avoided in clients with dementia, as it can lead to increased agitation, frustration, and a decline in physical function. Restraining a client is only appropriate in situations where the client is at imminent risk of harm to themselves or others and no other interventions are effective. It should always be a last resort and closely monitored by healthcare providers.

Administer PRN lorazepam (Ativan) to provide sedation:

While lorazepam may be used to manage anxiety or agitation, it is not appropriate for managing wandering behaviors. Sedation may impair the client's ability to ambulate safely and is not a recommended intervention for wandering. Additionally, sedatives can increase the risk of falls or confusion, especially in the elderly.

Summary:

The correct answer is B) Assess the client's gait for steadiness. This approach ensures that the nurse evaluates the client's physical safety and implements appropriate precautions to prevent falls while walking in the halls. Avoiding the use of unnecessary medications or restraints is crucial in the care of clients with dementia.

The correct answer is: The dialysate outflow is cloudy.

Explanation:

Cloudy dialysate outflow is a significant concern during peritoneal dialysis (PD) as it is a key indicator of a potential peritonitis infection, which can be caused by contamination during the procedure or an infection of the peritoneal cavity. Peritonitis is a serious complication that can lead to further health deterioration and requires immediate medical attention. Therefore, cloudy dialysate outflow necessitates an intervention by the nurse, which may include obtaining a sample for culture and notifying the healthcare provider for further evaluation and treatment, often with antibiotics.

Why the other options are incorrect:

The client complains of pain during the inflow of the dialysate.

Some discomfort or mild pain during the inflow of the dialysate can occur, especially if the abdominal cavity is distended or if the fluid is infused too rapidly. However, mild pain or discomfort is not necessarily an immediate concern unless it is severe or persistent, in which case further assessment would be necessary.

The client complains of constipation.

Constipation is a common complaint in clients undergoing peritoneal dialysis because the presence of dialysate in the abdominal cavity can put pressure on the intestines and hinder normal bowel movements. While it is uncomfortable, constipation is generally not an emergency situation unless it causes significant discomfort or leads to complications such as bowel obstruction. The nurse may recommend laxatives or dietary changes to address constipation.

There is blood-tinged fluid around the intra-abdominal catheter.

Blood-tinged fluid around the catheter is not uncommon, especially during the initial exchanges after the catheter is placed. Small amounts of blood may be seen due to irritation of the peritoneal lining or catheter insertion site. If the blood persists or increases, further evaluation would be necessary, but mild blood-tinged fluid alone does not immediately require intervention.

Summary:

Cloudy dialysate outflow is the most concerning finding, as it suggests possible peritonitis and requires immediate attention. The other findings, while needing monitoring, do not pose an immediate threat to the client's health.

The correct answer is : Reapplying a condom catheter for a client who has urinary incontinence.

Explanation:

When delegating tasks to an assistive personnel (AP), it is essential to consider the complexity of the task, the client's condition, and the level of training required. The AP is typically trained to handle tasks that are routine, non-invasive, and that do not require clinical judgment or assessment.

In this case, reapplying a condom catheter is a routine, non-invasive procedure that does not require clinical judgment or specialized knowledge. The AP can perform this task under the nurse's supervision. The key here is that the task is straightforward and does not require a skilled intervention, assessment, or evaluation of the client's condition.

Why the other options are incorrect:

Feeding a client who was admitted 24 hours ago with aspiration pneumonia:

Reason for inappropriateness for delegation to an AP: Feeding a client with aspiration pneumonia involves assessing the client's ability to swallow, monitoring for signs of aspiration, and managing the risk of aspiration pneumonia. This task requires the nurse's clinical judgment, especially since aspiration can lead to serious complications, such as further respiratory distress or pneumonia. Therefore, feeding a client in this condition should be done by a nurse, not an AP.

Reinforcing teaching with a client who is learning to walk with a quad cane:

Reason for inappropriateness for delegation to an AP: Reinforcing teaching about walking with a quad cane requires the nurse's clinical expertise and the ability to assess the client's understanding, safety, and technique. Teaching mobility aids requires a more in-depth understanding of the client’s condition and abilities, and the nurse must evaluate the client’s progress and adjust the teaching accordingly. An AP does not have the training to provide this type of education effectively.

Applying a sterile dressing to a pressure ulcer:

Reason for inappropriateness for delegation to an AP: Applying a sterile dressing to a pressure ulcer is a sterile procedure that involves assessing the wound for signs of infection, monitoring for changes in the wound bed, and ensuring that the dressing is applied properly. These tasks require critical thinking and clinical assessment to evaluate the wound's status and prevent further complications. Therefore, this task should be performed by a nurse, not an AP.

Summary:

The AP can safely be assigned the task of reapplying a condom catheter because it is a routine, non-invasive procedure that does not require clinical judgment or assessment. The other tasks involve critical thinking, assessment, or teaching that are best performed by a nurse.

The correct answer is:  a client with Alzheimer's requiring assistance with feeding.

Explanation:

A nursing assistant (NA) is typically trained to assist with basic care tasks that do not require a licensed professional's clinical skills or decision-making abilities. In this case, assisting a client with Alzheimer's disease who requires help with feeding falls within the scope of the NA's duties. This task involves providing assistance with feeding and ensuring the client’s safety while eating, which is a routine, non-invasive intervention.

Why the other options are incorrect:

A client with osteoporosis complaining of burning on urination.

This client’s complaint of burning on urination suggests a possible urinary tract infection (UTI) or other urological issue. Assessing symptoms such as this and initiating care (e.g., recommending urine tests, determining treatment) requires clinical judgment, which is outside the scope of practice for a nursing assistant. The RN or LPN should be responsible for investigating the symptoms.

A client with scleroderma receiving a tube feeding.

Scleroderma involves autoimmune effects that could impact several systems, including the gastrointestinal system. Tube feedings require careful monitoring, including verifying the placement of the feeding tube, ensuring proper administration, and observing for complications such as aspiration. These tasks are more appropriate for a RN or LPN than a nursing assistant due to their clinical complexity.

A client with cancer who has Cheyne-Stokes respirations.

Cheyne-Stokes respirations are irregular, often seen in severe illness or end-of-life care. This breathing pattern can indicate respiratory distress and requires careful assessment, potentially interventions like oxygen management, and observation of the client’s overall condition. This requires clinical expertise and should be managed by a nurse (RN or LPN), not a nursing assistant.

Summary:

The most appropriate assignment for a nursing assistant is caring for a client with Alzheimer's disease who requires assistance with feeding, as this task involves basic support and does not require advanced clinical assessment or judgment. Therefore, the correct answer is a client with Alzheimer's requiring assistance with feeding.

Correct Answer:  avoid palpating the abdomen when bathing the child before surgery

Explanation:

Wilm's tumor, also known as nephroblastoma, is a type of kidney cancer that typically affects children. It is important to avoid palpating the child's abdomen before surgery because the tumor is usually located in the kidney, and palpating the abdomen could cause the tumor to rupture or disseminate cancer cells to other parts of the body. Gentle care should be taken when bathing and handling the child, and any examination or manipulation of the abdomen should be avoided.

Why the other options are incorrect:

refrain from auscultating the child's bowel sounds during the postoperative assessment – This is incorrect because auscultating bowel sounds is an important part of the postoperative assessment, especially following abdominal surgery. It helps assess whether the child's bowel function has returned and if there are any complications like bowel obstruction or ileus. This should not be avoided.

encourage the child to play with other children on the unit prior to surgery – It is generally not advisable to encourage a child with a Wilm's tumor to play with other children before surgery, as the child may be more susceptible to infection or fatigue due to the tumor and the possible preoperative treatments like chemotherapy. Also, the child may be experiencing pain, discomfort, or anxiety that could be exacerbated by physical activity or interaction with others before surgery.

explain to the child that their pain will be managed after the surgery – While it is important to reassure the child that pain will be managed, this statement alone does not provide enough context or support for preoperative anxiety. It would be better to also explain what will happen during the surgery and address any concerns the child may have. Additionally, explaining pain management in simple terms and addressing the child's emotional and psychological needs are just as important before surgery.

Summary:

The priority intervention is to avoid palpating the abdomen in a child with Wilm's tumor to prevent the potential rupture of the tumor or dissemination of cancer cells. Preoperative care should focus on gentle handling, proper preparation for surgery, and managing the child's emotional state while avoiding actions that may lead to harm, such as unnecessary palpation. Other assessments, like auscultating bowel sounds, should be performed as needed during the postoperative assessment, and the child’s interactions with others should be carefully considered based on their condition

The correct answer is: Mononucleosis is caused by an infection with the Epstein-Barr virus.

Rationale:

Infectious mononucleosis, often referred to as "mono," is primarily caused by the Epstein-Barr virus (EBV), a member of the herpesvirus family. It is a viral infection that commonly affects adolescents and young adults and is spread through the exchange of saliva, which is why it's often called the "kissing disease." This statement accurately identifies the viral etiology of the disease.

Why the other options are incorrect:

Mononucleosis is a bacterial infection requiring 14 days of antibiotics. – This is incorrect because mononucleosis is caused by a virus (Epstein-Barr virus), not bacteria. Therefore, antibiotics are not effective in treating viral infections like mononucleosis. Antibiotics should only be prescribed for bacterial infections.

A Monospot is a throat culture used to diagnose mononucleosis. – This is incorrect because a Monospot is a blood test, not a throat culture. The Monospot test detects heterophile antibodies, which are often present in the blood of individuals infected with Epstein-Barr virus. It is commonly used to diagnose mononucleosis, but it is not a throat culture.

Children who get mononucleosis will need to refrain from sports for 6 months. – While it's true that children with mononucleosis are advised to avoid strenuous physical activity, especially contact sports, for a period of time due to the risk of splenic rupture (because the spleen can become enlarged during the infection), the typical recommendation is to avoid sports for at least 3 to 4 weeks, not 6 months. The duration of restriction is usually shorter, depending on the resolution of symptoms and the healthcare provider's advice.

Summary:

The correct understanding is that infectious mononucleosis is caused by the Epstein-Barr virus, making option A the most accurate.

Correct answer: Semi-Fowler's position.

Explanation:

This position promotes easier breathing and helps prevent aspiration, which is crucial during recovery from anesthesia and after the procedure. The semi-Fowler's position involves elevating the head of the bed to a 30-45 degree angle, which facilitates respiratory function, enhances lung expansion, and reduces the risk of aspiration. It also supports proper drainage of secretions and overall respiratory comfort, making it the most appropriate position for recovery.

Why the other options are incorrect:

Prone, with the head turned to the side: While the prone position may be appropriate in some cases for specific conditions like respiratory distress, it is not ideal after a bronchoscopy, as it could increase the risk of aspiration or compromise respiratory function.

With the head of the bed elevated 45° and the neck extended: While this position might support lung expansion, excessive neck extension can lead to discomfort and may interfere with the patient's airway. The semi-Fowler's position is a more comfortable and safer choice.

Supine, with the head in the midline position: The supine position can increase the risk of aspiration, particularly after a procedure like bronchoscopy. It does not facilitate optimal lung expansion and can be less comfortable for the patient post-procedure.

Summary:

The semi-Fowler's position is the most appropriate for an 8-year-old patient post-bronchoscopy as it promotes breathing, helps prevent aspiration, and supports recovery following anesthesia and the procedure.

Correct answer: Confused with cold, clammy skin and a pulse of 110.

Explanation:

A blood sugar of 50 mg/dL indicates hypoglycemia, which occurs when blood glucose levels fall too low. The symptoms of hypoglycemia include confusion, cold and clammy skin, and a rapid pulse as the body attempts to counteract the drop in blood sugar. The nurse should expect the client to exhibit these symptoms of hypoglycemia and should intervene by providing a quick source of glucose, such as a glucose tablet or juice.

Why the other options are incorrect:

Lethargic with hot, dry skin and rapid, deep respirations: This description is more indicative of hyperglycemia or diabetic ketoacidosis (DKA), where blood sugar levels are too high. Symptoms of hyperglycemia include lethargy, dry skin, and rapid, deep breathing (Kussmaul respirations), which are not present with hypoglycemia.

Alert and cooperative with a BP of 130/80 and respirations of 12: This would describe a person with normal blood sugar levels. A blood sugar of 50 mg/dL is low and would not result in a normal clinical status like this. The person would likely exhibit signs of hypoglycemia, such as confusion and cold, clammy skin, rather than being alert and cooperative.

Short of breath, with distended neck veins and a bounding pulse of 96: These symptoms are more consistent with heart failure or fluid overload, not hypoglycemia. Hypoglycemia typically causes symptoms related to the autonomic nervous system response, such as rapid pulse and sweating.

Summary:

A blood sugar of 50 mg/dL indicates hypoglycemia. The expected symptoms are confusion, cold, clammy skin, and a rapid pulse, which aligns with option A. Immediate treatment with a quick source of glucose is necessary to raise the blood sugar to a safer level.