ATI RN Fundamentals Exam

Correct Answer A. The client reports frequently having a headache in the morning.

Explanation of Correct Answer:

A. The client reports frequently having a headache in the morning.

Frequent morning headaches may be indicative of sleep apnea or another sleep-related disorder, such as bruxism (teeth grinding) or poor sleep quality. It is important for the nurse to report this finding to the provider, as it could signal a more serious underlying condition that requires evaluation and intervention. Morning headaches can be a result of interrupted sleep or low oxygen levels during sleep.

Why the Other Options Are Incorrect:

B. The client reports having vivid dreams about their childhood.

Vivid dreams, while they can be unsettling or unusual, are generally not a reason to report to the provider unless they are accompanied by other signs of sleep disturbance or sleep disorders. Vivid dreams are common and not necessarily indicative of an underlying medical issue.

C. The client reports taking 30 min to fall asleep on average.

Taking 30 minutes to fall asleep is within the normal range for many people and doesn't necessarily indicate a problem. Typically, it is considered normal if it takes anywhere from 10 to 30 minutes to fall asleep, and this alone does not require intervention.

D. The client reports sleeping about 7 hr on average.

7 hours of sleep is within the recommended range for adults (typically 7 to 9 hours per night). Therefore, this finding is not a concern and does not need to be reported to the provider. However, if the client is experiencing daytime sleepiness or other symptoms, this could be worth further exploration.

Correct Answer: Allow the client to hear running water while attempting to void.

After abdominal surgery, it is common for a patient to experience temporary difficulty with voiding due to factors like anesthesia, pain, or immobility. One common nursing intervention to stimulate the urge to void is to allow the client to hear running water, as it can trigger a reflex to initiate urination. This technique takes advantage of the body's natural association with water and the urge to void, potentially easing the process of urination without resorting to more invasive measures initially.

Why the other options are wrong:

Insert an indwelling urinary catheter and connect it to gravity drainage:

This is an invasive intervention that should not be the first step unless absolutely necessary. Inserting a catheter carries risks such as infection and injury, and it is generally avoided if other non-invasive options are available. The difficulty voiding postoperatively is typically temporary and often resolves without the need for catheterization.

Provide the client a bedpan while lying supine:

While using a bedpan may be appropriate for some patients, having the client lie supine may make voiding more difficult, especially if the patient is in pain or uncomfortable. The position could hinder the natural process of urination, and other positions or interventions (like allowing them to hear running water) may be more effective in promoting voiding.

Encourage fluid intake up to 1,000 mL daily:

Encouraging fluid intake is important for overall health, but limiting the fluid intake to 1,000 mL may not be adequate or appropriate for all clients, especially those recovering from surgery. Overly restricting fluid intake may not directly address the immediate issue of urinary retention and could potentially lead to dehydration. It's also essential to consider any contraindications, such as kidney function or fluid balance concerns, before recommending specific fluid intake amounts.

Summary:

The most appropriate intervention for a client who is 6 hours postoperative and having difficulty voiding is to allow them to hear running water while attempting to void. This non-invasive technique can help stimulate the urge to urinate. Inserting a catheter, using a bedpan while supine, or overly restricting fluid intake are less appropriate initial approaches and should be considered only if other interventions fail or the situation worsens.

The correct answer is: "I will leave a light on in my bathroom at night."

This statement indicates an understanding of safety considerations for an older adult client with heart failure who is taking hydrochlorothiazide, a diuretic. One of the side effects of diuretics is increased urination, especially at night (nocturia). Leaving a light on in the bathroom at night will help the client safely navigate the bathroom to reduce the risk of falls when getting up at night.

Why the Other Options Are Incorrect:

"I will weigh myself once weekly."

For clients with heart failure, weight should be monitored daily, especially when they are on diuretics, to assess for fluid retention or loss. A sudden increase in weight can be a sign of fluid retention, which could worsen heart failure. Weekly weight checks would not provide timely information about fluid status.

"I will take my new medication in the evening."

 Hydrochlorothiazide, a diuretic, is best taken in the morning to minimize the risk of nocturia and frequent trips to the bathroom during the night. Taking it in the evening could cause the client to wake up frequently to urinate, disturbing their sleep and potentially increasing the risk of falls.

"I will take a hot bath before going to bed."

 A hot bath can cause vasodilation and lower blood pressure, which may be risky for someone with heart failure, especially if they are taking diuretics like hydrochlorothiazide, which can also lower blood pressure. The combination could increase the risk of dizziness and falls. It's generally safer to avoid hot baths or showers before bed for clients with heart failure.

Summary:

For the older adult client with heart failure and a new prescription for hydrochlorothiazide, the appropriate safety consideration is to leave a light on in the bathroom at night to prevent falls due to nocturia. The other options involve practices that could increase the risk of falls or fail to adequately address the client's health needs (such as daily weight monitoring and proper timing of medication).

The correct answer is Measure the length of the client's leg from the heel to the gluteal fold.

When applying knee-length antiembolic stockings, the nurse must ensure they are properly fitted to the client's leg for effective support and prevention of deep vein thrombosis (DVT) or other circulatory issues.The correct way to measure for knee-length antiembolic stockings is from the heel to the gluteal fold to ensure they provide proper compression and fit the client's leg appropriately.

Why the Other Options Are Incorrect:

Instruct the client to point their toes while applying the stockings:

Pointing the toes while applying antiembolic stockings can lead to improper placement or fit. The stockings should be applied while the client's leg is in a neutral position (not pointed or flexed) to ensure proper compression and comfort.

Roll the top of the client's stockings down to just below the knee:

Rolling the stockings down below the knee is not a recommended practice, as it can reduce the effectiveness of the stockings in preventing venous stasis and DVT. The stockings should remain in place, covering the knee, to ensure proper compression and blood flow.

Seat the client in a chair for 30 min prior to applying the stockings:

This is unnecessary. There is no specific requirement to seat the client for 30 minutes before applying antiembolic stockings. The key is to ensure the client’s legs are not swollen, and the stockings are applied when the client is in a supine position or when the legs are in a resting position to avoid complications such as swelling or improper fit.

Summary:

The nurse should measure the length of the client's leg from the heel to the gluteal fold to ensure the knee-length antiembolic stockings fit properly and provide effective compression. Other actions, such as instructing the client to point their toes, rolling the stockings down, or seating the client before application, are not appropriate and may affect the stockings’ effectiveness.

The Correct Answer is D: Decreased attention span.

This is the correct answer

because decreased attention span can be a sign of a hearing deficit. Individuals with hearing loss may have difficulty concentrating on tasks because they are unable to fully engage in conversations or pick up on important auditory cues. This can lead to frustration and a reduced ability to focus, as they might miss parts of interactions or information.

Why the other choices are incorrect:

A) Presence of expressive aphasia

This is incorrect because expressive aphasia is a speech and language disorder caused by brain damage, often from a stroke or neurological conditions, and is not directly related to hearing deficits. It impacts one's ability to produce speech but does not affect hearing.

B) No response to tactile stimuli

This is incorrect because no response to tactile stimuli suggests a problem with the sense of touch or neurological response, not hearing. It is not a typical indicator of a hearing deficit.

C) Persistent repositioning of objects

This is incorrect because persistent repositioning of objects is not a specific sign of hearing loss. It could be indicative of a behavioral or cognitive issue, but it's not directly related to auditory function.

Summary:

The correct answer is D) Decreased attention span, as difficulty with hearing can lead to a decreased ability to pay attention due to missed auditory cues. The other options reflect symptoms that are unrelated to hearing loss.

The correct answer is: B. "Flush the tube with water prior to administration, between each medication and post administration."

Explanation:

B. "Flush the tube with water prior to administration, between each medication and post administration."

This is the correct statement. When administering medications through a nasogastric (NG) tube, it is essential to flush the tube with water before giving medications to ensure the tube is patent and clear. Flushing between each medication prevents the medications from interacting with each other inside the tube, which could lead to clumping or reduced effectiveness. Flushing after all medications helps clear any residue from the tube and maintains its patency, ensuring the full dose of medication is delivered safely and preventing blockage.

Why the other choices are incorrect:

A. "Administering medications prior to checking for compatibility with enteral nutrition formula."

This statement is incorrect. Before administering any medications via an NG tube, the nurse must check for compatibility between the medications and the enteral feeding formula. Certain medications may not be compatible with the formula, which can lead to reduced effectiveness, harmful interactions, or clogging of the tube. Skipping this step can compromise the patient’s safety and the efficacy of the treatment.

C. "Keep the head of bed at 30 degrees or lower to prevent aspiration."

This statement is incorrect. The head of the bed should be elevated to at least 30 to 45 degrees during medication administration through an NG tube to reduce the risk of aspiration. A lower head-of-bed position increases the risk of gastric contents or medications being aspirated into the lungs, which can cause serious complications such as aspiration pneumonia.

D. "Reapply the nasogastric tube to suction ten minutes after medication administration."

This statement is incorrect. After administering medications via an NG tube, suction should typically be delayed for at least 30 minutes or longer (according to facility policy) to allow adequate time for medication absorption. Reapplying suction too soon after giving medications can remove the medications from the stomach before they have been absorbed, reducing their effectiveness.

Summary:

The correct nursing action when administering medications via an NG tube is to flush the tube with water before, between, and after each medication to prevent interactions, ensure the tube stays clear, and promote full delivery of the medications. The other options describe incorrect practices that could harm the patient or reduce the effectiveness of the medications.

The correct answer is A. Give an around-the-clock schedule for administration of analgesics.

Option A (Give an around-the-clock schedule for administration of analgesics): In hospice care, the focus is on comfort and pain management for clients nearing the end of life. Around-the-clock analgesic administration is often preferred to prevent pain from becoming unmanageable and to maintain a consistent level of comfort. Pain in terminally ill patients can escalate quickly, so it's important to keep pain well-controlled before it becomes severe. This method can also avoid the fluctuations in pain that may occur with "as-needed" dosing, leading to better overall comfort

Why the other options are wrong:

Option B (Administer analgesic medication as needed when the pain is severe): Waiting until the pain is severe is not ideal in hospice care. Pain management should aim to prevent the pain from reaching a severe level. This option risks the client experiencing unnecessary discomfort. An around-the-clock schedule helps keep pain at a manageable level without waiting for it to escalate.

Option C (Provide medication to keep the client sedated and unaware of stimuli): The goal in hospice care is comfort, not sedation or unconsciousness. Clients should be kept comfortable but still conscious and alert enough to engage with their environment and loved ones. Sedating clients unnecessarily can deprive them of important emotional experiences during their final days.

Option D (Offer a medication-free period so that the client can do daily activities): For a client in hospice care, medication-free periods are not appropriate if they are in pain. The priority is pain management and comfort. Offering a medication-free period could leave the client in distress and potentially worsen their pain, which is counterproductive to their overall well-being in hospice care.

Summary

In hospice care, providing an around-the-clock schedule for analgesics ensures that pain is consistently managed, preventing it from becoming severe. This approach focuses on maintaining comfort and quality of life for the client, without waiting for pain to become unmanageable.