ATI NUR 109 Final Assessment Exam

The correct answer is A: The client may experience pain and discomfort due to the progression of their illness.

Explanation:

Mrs. Thompson is in the end-of-life stage with advanced metastatic cancer and is receiving palliative care. The primary goal of care at this stage is to maintain comfort and relieve suffering, not to prolong life or aggressively monitor disease progression. Pain and discomfort are common as terminal illness advances, and unmanaged symptoms can significantly reduce quality of life.

Mrs. Thompson is semi-conscious with signs such as irregular breathing, cool mottled skin, and fluctuating vital signs—all indicators of active dying. These findings emphasize the importance of comfort-focused interventions, such as effective pain management and symptom control. This makes addressing potential pain and discomfort the top priority in the care plan.

Why the other options are incorrect:

B.The client may have elevated blood pressure due to an acute exacerbation of their condition.

The client’s blood pressure is low, not elevated. In the end-of-life stage, hypotension is expected and is part of the natural dying process. Elevated blood pressure is not a relevant concern at this point.

C. The client may need increased physical therapy sessions to maintain mobilityP

hysical therapy to maintain mobility is not appropriate at this stage. Mrs. Thompson is semi-conscious and nearing death. The focus should be on comfort, not rehabilitation or mobility enhancement.

D.The client may benefit from additional laboratory tests to monitor disease progression.

Monitoring disease progression with laboratory tests is not aligned with the goals of palliative or end-of-life care. These interventions can be burdensome and do not contribute to comfort or quality of life.

Summary:

The hypothesis that should be prioritized is Option A, as it addresses the most immediate and appropriate need for a client in the end-of-life stage: ensuring comfort and managing pain effectively.

The correct answer is D: Perform bladder scan

Explanation:

A bladder scan is the non-invasive, immediate, and most appropriate first step in evaluating urinary retention after surgery. It allows the nurse to determine whether the bladder is distended with urine, which guides the next action—such as catheterization or provider notification. Delayed voiding after surgery can occur due to anesthesia, pain, immobility, or medications, and must be assessed promptly.

Why the other options are incorrect:

A. Encourage patient to increase fluid intake

While hydration is important, the patient may already have a full bladder, and encouraging fluids without assessing could worsen discomfort or retention.

B. Insert intermittent catheter

This may become necessary, but only after confirming urinary retention with a bladder scan. Catheterization without confirmation may be unnecessary or invasive.

C. Notify provider

The provider should be informed after the nurse gathers assessment data (i.e., bladder scan results) to guide the conversation and any further orders.

Summary:

Option D is correct because performing a bladder scan is the priority assessment to determine whether urinary retention is present and what intervention is needed.

The correct answer is D: Place ID bracelet on client indicating latex allergy

Explanation:

The immediate priority in response to an allergy—especially one with the potential for serious reactions like latex allergy—is to ensure the client is clearly and visibly identified to all caregivers. Applying a latex allergy ID bracelet ensures that anyone providing care is instantly aware and can take necessary precautions to avoid latex exposure, such as using latex-free gloves and equipment.

Why the other options are incorrect:

A. Place “Allergic to Latex” sticker on client chart

This is important for documentation, but it is not the most immediate or visible safety measure compared to an allergy ID bracelet.

B. Verbally notify staff of allergy

Verbal notification is helpful, but it relies on memory and verbal transmission, which can be missed. A visible alert on the patient, like an ID bracelet, is more reliable.

C. Notify provider of allergy

The provider does need to know, but patient safety comes first, and that starts with immediate, visible identification to prevent accidental exposure.

Summary:

Option D is correct because placing a latex allergy ID bracelet on the patient is the fastest and most effective way to alert all healthcare workers and prevent an allergic reaction.

The correct answer is A: Autonomy

Explanation:

Autonomy is the ethical principle that refers to an individual's right to make their own decisions regarding their body and treatment, as long as they have the capacity to do so. In this case, the client with an eating disorder is refusing to drink a prescribed supplement. If the nurse respects that decision, they are upholding the client’s autonomy—even if the refusal goes against medical advice.

This principle is central to patient-centered care and informed consent. Even when the healthcare team believes a treatment is beneficial, they must respect the patient’s right to refuse it if the patient is mentally competent and informed of the consequences.

Why the Other Options Are Incorrect:

B. Fidelity

Fidelity refers to being faithful to commitments made to the client and maintaining trust. While important in all care relationships, this situation is more specifically about respecting the client’s decision-making rights.

C. Veracity

Veracity involves truth-telling and honesty. It is essential in client education and communication but is not directly related to allowing the client to refuse a supplement.

D. Beneficence

Beneficence is the ethical duty to promote good and act in the client’s best interest. Encouraging the client to take the supplement would align with beneficence, but allowing them to refuse it demonstrates autonomy.

Summary:

By allowing the client to refuse the supplement, the nurse is honoring the ethical concept of autonomy (Option A), which supports the client’s right to make informed decisions about their own care.

The correct answer is A: Ensure that all electrical cords and wires are secured against walls and out of walkways.

Explanation:

Clients with glaucoma experience peripheral vision loss, which increases the risk of tripping over unseen obstacles, especially those located outside of central vision fields. Unsecured electrical cords and wires in walkways present a major fall hazard for visually impaired individuals. Prioritizing the removal or securing of these tripping hazards is essential for ensuring immediate physical safety in the home environment.

While other options also support a safer environment or improved navigation, eliminating immediate hazards that could cause injury is the most critical first step in fall prevention and home safety for clients with low vision.

Why the Other Options Are Incorrect:

B. Install bright, overhead lighting...

Improved lighting is helpful but does not address the specific hazard of physical obstructions, which poses a more immediate risk for falls in glaucoma patients.

C. Place throw rugs and carpets...

This is incorrect and dangerous. Throw rugs increase the risk of tripping and slipping, especially for those with vision loss, and should be removed, not added.

D. Encourage the client to use a walking stick or guide dog...

While assistive devices are beneficial for orientation and independence, this option may not be immediately practical or accessible and doesn’t address environmental hazards.

E. Label kitchen cabinets and drawers...

Labeling helps with independence in daily activities but is secondary to ensuring a hazard-free, physically safe environment.

Summary:

The most immediate and safety-focused intervention is A, securing electrical cords and wires to prevent falls—this directly addresses the major risk posed by visual impairments like glaucoma.

The correct answer is E: Unstageable

Explanation:

A wound is classified as unstageable when full-thickness tissue loss is present, but the wound bed is completely obscured by eschar (dead tissue) or slough, preventing the ability to determine the depth of tissue involvement. Until the eschar or slough is removed (debrided), the true stage cannot be identified, because deeper structures such as fascia, muscle, tendon, or bone may be involved.

Why the other options are incorrect:

A. Stage I

This involves intact skin with non-blanchable redness and no tissue loss. Eschar would not be present.

B. Stage II

Stage II is partial-thickness skin loss involving the epidermis and/or dermis. It may present as a blister or shallow open ulcer. Eschar is not characteristic of this stage.

C. Stage III

Stage III involves full-thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. However, if eschar is obscuring the wound bed, the wound cannot be staged as III without debridement.

D. Stage IV

Stage IV includes full-thickness tissue loss with exposed bone, tendon, or muscle. Again, if the wound bed is covered with eschar, exposure cannot be confirmed, making the wound unstageable.

Summary:

Option E is correct because when a wound has eschar covering the bed, making it impossible to determine the depth, it must be classified as unstageable until the eschar is removed and the full extent of damage is visible.

The correct answer is B: Continue to orient

Explanation:

For patients with dementia and confusion, especially in unfamiliar environments like a hospital after surgery, ongoing reorientation is essential. The RN should frequently reorient the patient to person, place, and time, using clocks, calendars, staff introductions, and explanations of procedures. This reduces confusion, helps maintain cognitive function, and decreases the risk of delirium and anxiety.

Why the other options are incorrect:

A. Keep a routine

While maintaining a routine can be helpful, especially at home or in long-term care, it is not as critical in the acute care setting as frequent reorientation, especially after a major event like surgery.

C. Allow several choices

Offering too many choices to a patient with dementia can increase confusion and frustration. It's better to offer limited, simple options to support decision-making without overwhelming the patient.

D. Socially isolate the patient

This is harmful, as isolation can worsen confusion, anxiety, and cognitive decline. Social interaction should be encouraged, not restricted.

Summary:

Option B is correct because frequent reorientation is a core nursing intervention for patients with dementia and confusion, especially in unfamiliar or stressful environments like post-operative care.

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 D: Cultural competence involves understanding and respecting diverse cultural backgrounds and incorporating this understanding into client care to improve outcomes and client satisfaction.

Explanation:

Cultural competence in nursing refers to the ability of healthcare professionals to understand, respect, and respond appropriately to the cultural beliefs, values, and needs of diverse clients. This includes being aware of one's own cultural perspective, being open to learning about other cultures, and incorporating that knowledge into individualized care plans. When practiced effectively, cultural competence leads to improved health outcomes, increased client satisfaction, and stronger nurse-client relationships.

Why the other options are incorrect:

A. Cultural competence is only necessary when caring for clients from cultures that are significantly different from one's own.

Cultural competence is essential in all healthcare interactions, not just with clients who are "significantly different." Even small cultural differences can influence communication, decision-making, and care preferences.

B.Cultural competence requires that nurses adopt the cultural practices of their clients to provide the best care

Nurses should not adopt clients' cultural practices, but rather respect and accommodate them within safe and evidence-based care practices. The goal is to integrate cultural awareness, not to assume another identity.

C.Cultural competence means that healthcare providers must follow a standardized approach to care that applies to all clients, regardless of their cultural background.

A standardized approach ignores cultural nuances and does not reflect individualized care. Cultural competence requires flexibility and adaptation to meet the unique needs of each client.

Summary:

Option D best defines cultural competence by highlighting the importance of integrating cultural awareness into nursing care to respect diversity and improve health outcomes.