ATI NU 160 Exam 1 Spring 2025

Correct Answers:

Have the client remain in bed up to 6 hours.

Keep the client’s hip and leg extended.

Check peripheral pulses in the affected extremity.

Explanation of Correct Answers:

Have the client remain in bed up to 6 hours

After a cardiac catheterization, especially with a femoral artery approach, the client must stay on bed rest to prevent bleeding or hematoma formation at the insertion site. The duration of bed rest varies but is typically between 2 to 6 hours, depending on the type of closure device used.

Keep the client’s hip and leg extended

If the catheterization was performed through the femoral artery, the hip and leg on the affected side must remain extended to prevent pressure on the insertion site. Bending the hip or leg can lead to bleeding or arterial occlusion.

Check peripheral pulses in the affected extremity

After the procedure, circulation in the limb distal to the insertion site must be frequently assessed. This helps detect complications such as arterial occlusion, thrombosis, or hematoma formation. Peripheral pulse checks include assessing pedal pulses, capillary refill, skin temperature, and color.

Explanation of Incorrect Answers:

Measure the client’s vital signs every 4 hours

This is incorrect because vital signs must be monitored more frequently immediately after the procedure. The recommended schedule is every 15 minutes for the first hour, every 30 minutes for the next hour, then every hour for several hours before transitioning to routine checks.

Place the client in high-Fowler’s position

This is incorrect because sitting the client upright at 60 to 90 degrees can increase the risk of bleeding at the catheter insertion site. The client should instead remain supine or have the head of the bed elevated no more than 30 degrees to minimize pressure on the artery.

Summary:

After a cardiac catheterization, the nurse must focus on preventing bleeding and monitoring circulation. This includes keeping the client on bed rest, ensuring the affected limb remains extended, and frequently checking peripheral pulses. Vital signs should be monitored closely in the first few hours, and the client should not be placed in a high-Fowler’s position to avoid unnecessary pressure on the insertion site.

Correct Answer: C. The stoma is pale in color.

Why This Answer Is Correct

A pale stoma may indicate poor blood circulation or ischemia, which could lead to necrosis if left untreated. A healthy stoma should appear red or pink, indicating adequate blood supply. The nurse should report this finding to the provider immediately so appropriate interventions can be taken.

Why the Other Options Are Incorrect

A. The stool is yellow-green

The color of stool varies based on the location of the colostomy. A yellow-green stool is typical of an ascending or transverse colostomy, where the stool is still liquid. In a descending or sigmoid colostomy, stool is more formed. This is a normal finding unless accompanied by signs of infection or other complications.

B. The ostomy is draining frequently

Frequent drainage is expected early postoperatively and depends on the stoma's location. An ileostomy or early colostomy often has frequent liquid stool output. This is not necessarily a cause for concern unless there are signs of dehydration or electrolyte imbalances.

D. The skin around the stoma is red

 Redness around the stoma may indicate mild irritation from adhesive or stool leakage, but it is not always an emergency. The nurse should assess for skin breakdown or infection. If redness is accompanied by pain, swelling, or pus, it should be reported. Otherwise, proper stoma care can help manage mild irritation.

Summary

A pale stoma is a serious finding that may indicate ischemia or inadequate blood supply, requiring immediate medical attention. The other findings may be normal or manageable with routine stoma care and monitoring.

Correct Answer: B. Respiratory Alkalosis

Why the Correct Answer Is Respiratory Alkalosis:

Step 1: Determine if the pH is normal, acidic, or alkalotic.

pH = 7.50 (above normal range) → Indicates alkalosis

Step 2: Identify if the cause is respiratory or metabolic.

PaCO₂ = 22 mmHg (low) → Since CO₂ is acidic, a low PaCO₂ suggests excessive CO₂ loss (which makes the blood more alkaline).

HCO₃⁻ = 22 mEq/L (normal) → Since bicarbonate (a base) is within the normal range, the cause is not metabolic.

Conclusion:

Alkalotic pH + Low PaCO₂ + Normal HCO₃⁻ = Respiratory Alkalosis

Why the Other Options Are Incorrect:

A. Metabolic Acidosis

Acidosis means the pH would be low (<7.35), but in this case, the pH is high (alkalotic). HCO₃⁻ is normal; if metabolic acidosis were present, bicarbonate would be low (<22 mEq/L).

C. Metabolic Alkalosis

In metabolic alkalosis, HCO₃⁻ would be elevated (>26 mEq/L). Here, HCO₃⁻ is normal (22 mEq/L), ruling out a metabolic cause.

D. Respiratory Acidosis

Respiratory acidosis occurs when PaCO₂ is high (>45 mmHg), leading to a low pH (<7.35). In this case, PaCO₂ is low (22 mmHg) and pH is high, which is the opposite of respiratory acidosis.

Additional Considerations:

The PaO₂ of 42 mmHg is severely low, indicating hypoxemia

Common causes of respiratory alkalosis include:

Hyperventilation (due to anxiety, pain, fever, or hypoxia).

Pulmonary disorders (such as pulmonary embolism, pneumonia, or high-altitude sickness).

Mechanical ventilation set at high respiratory rates.

Summary:

This ABG result indicates respiratory alkalosis, as shown by high pH, low PaCO₂, and normal HCO₃⁻. The low PaO₂ suggests the presence of hypoxemia, which might be causing the hyperventilation leading to CO₂ loss.

Correct Answer: C. Encourage the client to take small bites.

Explanation:

Encouraging the client to take small bites is essential for safe swallowing in a patient with dysphagia following a stroke. Smaller bites reduce the risk of choking or aspiration, allowing the patient to control the food more effectively and swallow it safely. Patients with dysphagia often have impaired muscle control, so smaller bites and sips help them manage the swallowing process more efficiently. Additionally, thickened liquids and soft-textured foods are often recommended to further reduce the risk of aspiration.

Why the Other Options Are Incorrect:

A. Encourage brief exercise before meals to promote appetite.

While light exercise may stimulate appetite, it does not directly address feeding safety for a patient with dysphagia. The priority in dysphagia management is preventing aspiration, not increasing appetite. Some stroke patients may experience fatigue, so exercising before meals could make eating more difficult.

B. Place food in the affected side of the mouth.

Stroke patients often have weakness or paralysis (hemiparesis) on one side of the body, including the face and mouth. Placing food on the affected side increases the risk of food pocketing, aspiration, and choking because the patient may not have full sensory or motor control over that side. Instead, food should be placed on the unaffected (stronger) side to facilitate better chewing and swallowing.

D. Place the client with the head reclined back to facilitate swallowing.

Tilting the head back is dangerous for a patient with dysphagia because it increases the risk of aspiration by opening the airway. Instead, the Chin-Tuck Maneuver (tucking the chin slightly forward while swallowing) is often recommended, as it helps close the airway and direct food down the esophagus safely. Patients should be positioned upright (at least 90 degrees) during meals and should remain sitting for 30–60 minutes after eating to reduce aspiration risk.

Summary:

The correct answer is C. Encourage the client to take small bites, as this helps prevent choking and aspiration in a client with dysphagia. The other options are incorrect because placing food on the affected side increases aspiration risk, tilting the head back makes swallowing more dangerous, and exercise does not directly improve feeding safety. Proper positioning, slow eating, and monitoring for signs of aspiration are crucial when caring for stroke patients with swallowing difficulties.

Correct Answer: b. Douche 2X a month

Explanation:

Douching, even infrequently, is not recommended as an intervention to prevent urinary tract infections (UTIs). In fact, douching can disrupt the natural balance of bacteria in the vaginal area, which can lead to an increased risk of infections, including UTIs. The practice can also cause irritation and dryness, which may make the urinary tract more susceptible to infection.

Why the Other Options Are Correct:

a. Wear cotton underwear: Wearing cotton underwear is a recommended practice for preventing UTIs because cotton allows better air circulation and keeps the area dry, which helps reduce the growth of bacteria in the genital area. Synthetic fabrics can trap moisture and promote bacterial growth.

c. Avoid caffeine: Caffeine can irritate the bladder and worsen UTI symptoms, so avoiding or limiting caffeine intake can help reduce bladder irritation and decrease the likelihood of developing a UTI.

d. Urinate after sex: Urinating after sex is a well-established recommendation for preventing UTIs. It helps flush out any bacteria that may have entered the urethra during sexual activity, reducing the risk of infection.

Summary:

To prevent UTIs, it is important to wear cotton underwear, avoid caffeine, and urinate after sex. However, douching is not recommended and may actually increase the risk of developing UTIs, making it the incorrect intervention.

Correct Answer: C. Determine if the client uses hearing aids.

Explanation:

According to the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation), assessment is always the first priority. Before choosing a communication strategy, the nurse must first determine if the client uses hearing aids and if they are functioning properly.

Why This Is the Priority Action:

Assessing hearing aids first ensures the client has the best possible hearing ability before adjusting communication methods.

Many patients with hearing loss have hearing aids but may not be using them correctly, or they may need maintenance.

 Addressing physical barriers to communication before adjusting speech patterns is best practice.

Why the Other Options Are Incorrect:

 A. Speak using his usual tone of voice.

Speaking in a normal tone is helpful, but it does not address potential hearing aid use first. Some clients may need louder speech, while others may need clearer enunciation or lower-pitched tones.

 B. Stand directly in front of the client.

Facing the client is helpful for lip reading, but if the client needs hearing aids, this step alone won’t be effective. The priority is ensuring the client’s hearing aid is available and functioning before modifying communication.

 D. Rephrase statements the client does not hear.

Rephrasing helps clarify communication but should come after ensuring optimal hearing ability. If hearing aids are needed but not used, rephrasing will not effectively improve communication.

Summary:

 First, assess if the client uses hearing aids and ensure they are working.  Then, use appropriate communication techniques based on the client’s needs.

Correct Answer: Obtain an EKG

Explanation:

The client's symptoms—jaw, back, and shoulder pain, shortness of breath, and nausea—are classic signs of a myocardial infarction (MI), especially in women and older adults. The priority action is to obtain an EKG (electrocardiogram) to assess for any cardiac abnormalities, such as ST-segment elevation or depression, which may indicate a heart attack.

Why the Other Options Are Incorrect:

Maintain oxygen saturations greater than or equal to 92% – While maintaining oxygen saturation is important, the priority intervention in a suspected cardiac event is to confirm the diagnosis with an EKG before proceeding with oxygen therapy unless the patient is hypoxic.

Administer ibuprofen – Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are not recommended for chest pain due to their potential to increase the risk of cardiovascular events. Aspirin is preferred if an MI is suspected.

Administer enteric-coated acetaminophen – Acetaminophen is not an appropriate intervention for suspected MI, as it does not provide the antiplatelet effects needed in this situation. Aspirin (not acetaminophen) is typically given to help prevent further clot formation.

Summary:

The priority intervention for this client is to obtain an EKG to determine whether the symptoms are due to a myocardial infarction (heart attack). The nurse should then follow standard chest pain protocols, which may include administering oxygen, aspirin, nitroglycerin, and morphine, depending on the severity and diagnosis.

Correct Answer: B. The weights rest against the foot of the bed.

Explanation:

In skeletal traction, the weights must hang freely to maintain continuous traction and proper alignment of the fractured bone. If the weights are resting against the foot of the bed, they are not exerting the necessary force, which can lead to improper bone alignment and healing. The nurse should immediately reposition the weights to ensure they are hanging freely without obstruction.

Why the Other Options Are Incorrect:

A. The ropes are in the center of the wheel grooves.

Correct practice. The ropes should be in the center of the pulley's wheel grooves to ensure smooth movement and prevent friction that could interfere with traction.

C. The weights are equal on each side.

Correct practice. The weights should be equal on both sides to maintain balanced traction force, which helps prevent bone misalignment

D. The ropes are securely attached to the pins.

Correct practice. The ropes must be securely attached to the pins to ensure the proper function of the traction system and prevent accidental detachment that could disrupt alignment.

Summary:

The correct answer is B because weights should never rest against the bed—they must always hang freely to maintain proper traction. If the weights are obstructed, the nurse must reposition them to ensure continuous and effective traction.

Correct Answer:  Leaning in, facing the patient.

Explanation:

Active listening involves attentive body language, eye contact, and gestures that demonstrate engagement and understanding with the patient. Leaning in and facing the patient signals attentiveness, encourages communication, and fosters a therapeutic nurse-patient relationship.

Incorrect Answers & Rationale:

"Taking frequent notes."

Incorrect because while note-taking is sometimes necessary, excessive note-taking can distract from eye contact and hinder active engagement. Active listening requires focusing on the patient’s verbal and nonverbal cues rather than being preoccupied with documentation.

"Sitting with legs crossed."

Incorrect because crossing legs may indicate a closed-off posture and could make the patient feel less comfortable sharing personal information. Open body language, such as uncrossed legs and arms, is more welcoming and encouraging.

"Checking the clock frequently."

Incorrect because looking at the clock or watch may convey disinterest, impatience, or lack of concern for the patient’s needs. Active listening requires giving the patient undivided attention and being fully present during the interaction.

Summary:

Active listening behaviors include leaning in, facing the patient, nodding, and maintaining eye contact. These actions show genuine interest, support, and attentiveness, which are essential for effective nurse-patient communication.