ATI NUR 109 Final Assessment Exam

The correct answer is C: Respiratory rate 8/min

Explanation:

A respiratory rate of 8 breaths per minute is considered abnormally low and is a sign of respiratory depression, which is a serious adverse effect of opioid medications like morphine sulfate. Opioids suppress the respiratory centers in the brain, and close monitoring is required after administration—especially within the first 15 to 30 minutes when peak effects may occur. Respiratory depression is a medical emergency that requires immediate intervention, such as stopping the opioid, stimulating the patient, and possibly administering naloxone, an opioid antagonist.

Why the other options are incorrect:

A. Sleepy, but arousing when her name is called

This level of sedation is expected after morphine administration and is not considered an adverse effect as long as the client is easily arousable and maintains stable vital signs.

B. SaO₂ 94%

An oxygen saturation of 94% is within the acceptable range for most patients and is not considered an adverse effect.

D. Pain level of 6 on a scale from 0 to 10

This indicates that the morphine may not yet be fully effective, or the dose may be insufficient for the client’s pain level. However, this is not an adverse effect, but rather an issue of effectiveness.

Summary:

A respiratory rate of 8/min (Option C) indicates respiratory depression, which is a potentially life-threatening adverse effect of IV morphine sulfate and requires prompt nursing action.

The correct answer is C: Prolonged wound healing

Explanation:

In the acute care phase of burn management, the body is under significant metabolic stress, and the demand for protein, calories, and nutrients is substantially increased to support tissue repair and wound healing. Malnutrition—even short-term—can delay wound healing, weaken the immune response, and increase the risk of infection and other complications. If a burn patient is not consuming adequate nutrition, the RN should be especially alert for prolonged wound healing, as it is a direct and critical consequence.

Why the other options are incorrect:

A. Dehydration

While important in burn care, dehydration is more directly assessed through fluid balance and intake/output, not malnutrition. It is not a direct consequence of inadequate nutritional intake unless paired with poor fluid intake.

B. Dry brittle hair

This can be a sign of chronic malnutrition or certain deficiencies, but it is not as immediate or critical a concern in the acute phase of burn recovery as wound healing is.

D. Fingertip clubbing

Clubbing is usually associated with chronic hypoxia, lung disease, or cardiac issues and is not related to nutritional status or the acute care phase of burn recovery.

Summary:

Option C is correct because prolonged wound healing is a direct and serious consequence of malnutrition in burn patients, especially during the acute phase, when metabolic needs are at their peak for tissue repair and immune function.

The correct answers are:

A. Use materials written in the client's spoken language

B. Provide a variety of educational materials

C. Choose materials that include culturally relevant information and examples

E. Use pictures

Explanation:

A. Use materials written in the client's spoken language

Providing educational materials in the client’s spoken language helps ensure understanding and supports effective communication. It reduces language barriers and allows the client to engage meaningfully in their care and decision-making.

B. Provide a variety of educational materials

Using a combination of brochures, handouts, videos, and verbal instructions accommodates different learning styles and improves comprehension. A varied approach reinforces key information and helps ensure the client retains important details about their procedure and care.

C. Choose materials that include culturally relevant information and examples

Including culturally relevant content ensures that the material is respectful, relatable, and meaningful to the client. It helps bridge cultural gaps, builds trust, and promotes greater engagement with the information provided.

E. Use pictures

Visual aids are powerful tools in patient education, especially for clients with limited literacy or language skills. Pictures can help convey complex information quickly and clearly, enhancing understanding and recall.

Why the other option is incorrect:

D. Use materials written at a twelve-grade level

Educational materials should be written at a fifth- to sixth-grade reading level to ensure they are accessible to a broad range of clients, including those with limited literacy skills. Twelfth-grade level materials may be too complex and could lead to misunderstanding or confusion.

Summary:

The most appropriate guidelines for selecting written educational materials for a client with limited English proficiency are A, B, C, and E, as they promote clarity, cultural relevance, and accessibility.

The correct answer is B: Designing and delivering educational sessions on healthy lifestyle choices and preventive measures to the community.

Explanation:

Community health nursing focuses on promoting health and preventing disease at the population level. By designing and providing educational programs that address healthy lifestyle habits (such as nutrition, exercise, tobacco cessation, and stress management), the nurse plays a proactive role in preventing chronic diseases like diabetes, hypertension, and heart disease. This aligns with public health goals and the core mission of community health nursing, which is to improve health outcomes through education, prevention, and population-focused strategies.

Why the other options are incorrect:

A. Focusing solely on treating acute health issues as they arise within the community

This is a reactive approach, not a preventive one, and does not reflect the broader scope of community health nursing, which emphasizes prevention and health promotion.

C. Providing one-on-one medical treatment for community members who are currently experiencing chronic disease symptoms

While important, treatment is not the primary focus of a community health nurse. Their role emphasizes preventing disease and promoting wellness at the community level rather than individual clinical care.

D. Conducting individual health screenings and providing personalized counseling for each participant

Although helpful, this is more individual-focused and does not have the same community-wide impact as delivering group education sessions aimed at preventing chronic conditions.

Summary:

Option B best reflects the nurse’s role in promoting community health by empowering individuals through education and prevention to reduce the risk of chronic disease across the population.

The correct answer is C: Complete one task before starting another task

Explanation:

When managing multiple tasks, it is most effective for the RN to focus on completing one task at a time before moving on to the next. This approach reduces errors, improves concentration, and enhances task efficiency. Multitasking or starting several tasks simultaneously can lead to confusion, mistakes, and incomplete work. Prioritizing tasks and completing them sequentially ensures quality and safety in patient care.

Why the other options are incorrect:

A. Doing as much as possible alone before seeking help can lead to burnout and decreased quality of care. Collaboration and delegation are important.

B. Evaluating effectiveness only after completing all tasks delays recognition of problems that could be addressed sooner during care.

D. Delegating tasks based on personal preference rather than competency or appropriateness can compromise patient safety and team dynamics.

Summary:

Correct answer: C. The best approach is to complete one task before starting another, ensuring safe, focused, and effective nursing care during a busy shift.

The correct answer is B: Daily weight

Explanation:

Daily weight is the most accurate and sensitive indicator of fluid balance in patients, especially older adults. A sudden change in weight (typically measured at the same time each day using the same scale) reflects changes in total body water. Even a 1 kg (2.2 lbs) change in 24 hours may represent a 1-liter fluid gain or loss.

Why the other options are less accurate:

A. Skin turgor

In older adults, skin turgor is less reliable due to age-related skin changes (loss of elasticity), making it an inaccurate measure of hydration in the elderly.

C. Urinary output

While useful, urinary output can be affected by kidney function, medications, or retention, and may not reflect early fluid changes as accurately as daily weights.

D. Mucous membranes

Dry mucous membranes may indicate dehydration, but they are subjective and less precise than tracking daily weight

Summary:

Option B is correct because daily weight monitoring provides the most objective and reliable measure of hydration status, particularly in elderly patients with fluid loss.

The correct answer is A: Dakin's solution

Explanation:

Dakin’s solution is a sodium hypochlorite-based antiseptic that is effective at killing bacteria, but it is also cytotoxic, meaning it can destroy healthy cells, including fibroblasts and granulation tissue, which are essential for wound healing. For this reason, Dakin’s solution is typically only used for heavily contaminated wounds or wounds with necrotic tissue where infection control is prioritized over tissue preservation.

Why the other options are incorrect:

B. Normal saline

This is isotonic and non-cytotoxic, making it safe and appropriate for cleansing most wounds. It does not harm granulation tissue or fibroblasts.

C. Commercially prepared, non-cytotoxic wound cleansing solutions

These are formulated specifically to clean wounds without damaging viable tissue. They are commonly used for their safety and effectiveness in maintaining a healing environment.

D. Sterile water

Sterile water is non-cytotoxic and can be used for wound cleansing, although it is hypotonic, which may cause cell swelling if used in large quantities. Still, it does not destroy fibroblasts or granulation tissue.

Summary:

Option A is correct because Dakin’s solution is cytotoxic and can damage or delay healing by destroying fibroblasts and granulation tissue, making it inappropriate for routine wound care focused on healing.

The correct answer is C: Laxatives cause perforation if bowel obstruction is present

Explanation:

Administering a laxative to a patient with a known or suspected bowel obstruction is contraindicated because it can increase intraluminal pressure, potentially leading to bowel perforation, peritonitis, or sepsis. This is a serious and potentially fatal complication, regardless of whether the patient takes psyllium at home.

Why the other options are incorrect:

A. Call provider to see if standing order applies

While contacting the provider is generally prudent, the team lead should recognize that administering a laxative in this scenario is unsafe and should immediately discourage it without waiting for clarification, unless there’s a very specific instruction from the provider.

B. Give laxative according to standing order

This is unsafe. Standing orders should never override clinical judgment, especially when a bowel obstruction is involved.

D. Client cannot be constipated because she’s NPO

This is incorrect. Being NPO does not eliminate the possibility of constipation or obstruction, especially in patients with chronic bowel issues or recent surgery.

Summary:

Option C is correct because giving a laxative in the presence of a bowel obstruction is dangerous and can cause perforation, making it the most critical and accurate response to prevent harm.

The correct answer is D: Check with pharmacy for availability of liquid forms of medications

Explanation:

Administering multiple medications through an NG tube increases the risk of tube clogging, especially if the medications are crushed tablets or capsules that are not adequately diluted. Liquid formulations are preferred because they flow easily through the tube, reducing the risk of clogging. Checking with the pharmacy for liquid forms ensures the safest and most effective medication delivery method while minimizing complications.

Why the other options are incorrect:

A. Instilling non-liquid medications without diluting:

This practice increases the risk of tube obstruction as crushed or undiluted medications can clump and block the tube.

B. Irrigating the tube with 60 mL of water after all medications are given:

Although flushing the tube with water is important to maintain patency, the best preventive measure is to avoid clogging by using liquid meds or proper dilution, not just irrigation after administration.

C. Mixing all medications together:

Combining medications can lead to chemical incompatibilities, reducing drug effectiveness or causing adverse reactions. Medications should be administered separately with adequate flushing between them.

Summary:

Correct answer: D. To prevent NG tube clogging when multiple medications are prescribed, the RN should consult pharmacy for liquid formulations to ensure safe, effective, and uncomplicated administration.