ATI RN Fundamentals Exam

The correct answer is: The scale measures six elements.

The Braden Scale is used to assess a patient's risk for developing pressure ulcers. It evaluates six key areas:

Sensory Perception

Moisture

Activity

Mobility

Nutrition

Friction and Shear

Each of these six factors is rated on a scale, and the total score helps determine the level of risk. A lower score indicates a higher risk for pressure ulcer development.

Why the other options are incorrect:

Each element has a range 1 to 5 points: This is incorrect because the scoring for each element on the Braden Scale ranges from 1 to 4, not 1 to 5.

The higher the score the higher the pressure ulcer risk: This is incorrect. A higher Braden score actually indicates a lower risk for developing pressure ulcers. A lower score indicates a higher risk.

The client's age is part of the measurement: This is incorrect. The Braden Scale does not include age as one of the factors. It focuses on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Summary

Thus, the correct answer is that the Braden Scale measures six elements.

Correct Answer: Keep the cane on the unaffected side of the body.

The cane should be held on the unaffected side of the body. This helps provide balance and support to the weaker leg or affected side. By using the cane on the unaffected side, the patient can transfer weight more effectively to the cane and the stronger leg, which promotes stability and reduces the risk of falls.

Why the Other Options are Incorrect:

Advance the cane and the unaffected leg together:

When using a cane, the cane should be advanced first, followed by the weaker leg, and then the stronger leg. This ensures that the cane provides support as the weaker leg steps forward, promoting balance and stability.

Maintain the body weight on the stronger leg:

 The goal when using a cane is to help distribute body weight more evenly. The patient should place some weight on the cane to reduce the load on the affected or weaker leg, but the weight should not be placed entirely on the stronger leg. The cane helps to share the weight and maintain balance.

Move the cane forward 30.5 cm (12 in) when taking a step:

While the exact distance may vary, it is generally recommended to move the cane forward about 15 to 20 cm (6 to 8 inches) with each step. Moving the cane 30.5 cm (12 in) may be too far and could destabilize the client.

Summary:

The correct instruction is to keep the cane on the unaffected side of the body to provide balance and support for the weaker leg. The other instructions regarding advancing the cane and leg, weight distribution, and the distance moved by the cane are not consistent with proper cane usage.

The correct answer is: A) Leave the area.

The first step a child should take when they encounter a firearm is to leave the area immediately. This ensures that the child removes themselves from any potential danger before considering any other steps. The priority is to remove the child from the situation as soon as they encounter a firearm. This minimizes the risk of harm before any other actions are taken.

B) Do not touch the gun: While it is important not to touch the gun, the child should first get to a safe location. Touching or interacting with the gun should only be considered once they are in a safe space, away from the weapon.

C) Stop where he is: Stopping in place may not be the safest option. Leaving the area is the best immediate action to ensure the child's safety.

D) Tell an adult: Telling an adult is essential, but it should happen after the child has removed themselves from the dangerous situation. The first priority is to ensure the child is not in proximity to the weapon.

Summary:

When a child encounters a gun, the first action should be to leave the area to ensure their immediate safety. After that, they should avoid touching the firearm, stop moving, and inform an adult. This sequence helps reduce the risk of injury and ensures the child is removed from a potentially hazardous situation.

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 Performance of a paracentesis.

Informed consent is required for any procedure that is invasive, carries significant risk, or requires the client’s understanding and voluntary agreement to the procedure. A paracentesis, which involves the removal of fluid from the peritoneal cavity using a needle, is an invasive procedure that requires informed consent. The client must be informed about the risks, benefits, and alternatives before proceeding.

Why the Other Procedures Do Not Require Informed Consent:

Administration of an enema:

This is generally considered a routine procedure and does not usually require informed consent unless it is done in an unusual or high-risk context.

Insertion of an indwelling urinary catheter:

While this is an invasive procedure, it is typically done routinely and does not generally require formal informed consent unless there are specific concerns or risks.

Placement of an NG tube:

Insertion of a nasogastric (NG) tube is an invasive procedure, but in most cases, it is performed as part of routine care for clients who are unable to eat or swallow. Informed consent might be necessary in certain circumstances, but it is not always required for routine placement.

Summary:

Informed consent is most crucial for paracentesis, as it involves a significant risk to the client and is not routine care. The other procedures typically do not require formal informed consent unless specific circumstances necessitate it.

Correct Answer: Gloves

When removing personal protective equipment (PPE), the general rule is to remove the gloves first. Gloves are typically the most contaminated item during patient care, so they should be removed first to avoid spreading contaminants. This step minimizes the risk of self-contamination before moving on to other protective gear.

Why the Other Options are Incorrect:

Mask:

The mask should be removed last. The mask is considered the most important piece of PPE for preventing airborne transmission, and it should be removed after all other items to minimize the risk of contamination. If removed too early, the nurse could inadvertently breathe in contaminants when removing it.

Eyewear:

Eyewear should also be removed after the gloves. It's important to handle the eyewear by its outer surface to avoid contamination of the face, but gloves are the first priority for removal because they are most likely to be contaminated during patient care.

Gown:

The gown should be removed after the gloves. The gown is usually removed by pulling it away from the body without touching the outer surface, ensuring no contamination occurs. Removing the gown first could lead to contamination of the hands before gloves are removed.

Summary:

When leaving a room requiring airborne precautions, the nurse should remove gloves first, followed by the gown, eyewear, and mask. This order reduces the risk of contaminating oneself and others. Gloves are typically the most contaminated PPE, so they should be removed first to minimize exposure.

The Correct Answer is B: Tighten and relax muscles during relaxation therapy.

This is the correct answer

because progressive relaxation therapy involves systematically tensing and relaxing different muscle groups in the body to help the client become more aware of muscle tension and to promote relaxation. This technique helps to reduce stress by teaching the client how to recognize and release physical tension, which can improve overall relaxation and decrease anxiety.

Why the other choices are incorrect:

A) Take short and shallow breaths when meditating.

This is incorrect because the goal of meditation is to promote deep, slow breathing, which helps activate the parasympathetic nervous system and induces relaxation. Shallow breathing can increase tension and anxiety, which is counterproductive to the goals of meditation.

C) Plan to meditate immediately after meals.

This is incorrect because meditating immediately after meals can be uncomfortable. After eating, digestion requires energy and can make a person feel drowsy or uncomfortable, which can interfere with the focus needed for effective meditation. It's generally better to wait at least 30 minutes to an hour after eating before meditating.

D) Keep eyes open during relaxation therapy.

This is incorrect because during relaxation therapy, particularly when practicing progressive relaxation or meditation, it is usually advised to close the eyes to minimize distractions and help the client focus inward. Keeping the eyes open can interfere with the ability to relax and focus effectively.

Summary: The correct instruction is B) Tighten and relax muscles during relaxation therapy, which is a key aspect of progressive relaxation. The other options either hinder relaxation (shallow breathing, meditating immediately after meals) or distract from the relaxation process (keeping eyes open).

The Correct Answer is A: Fold the existing patch on itself and dispose of it in a childproof container.

This is the correct answer because when replacing a transdermal patch, the nurse should first remove the old patch, fold it on itself to contain any residual medication, and dispose of it in a childproof container to ensure it is safely discarded and prevent accidental exposure. The patch should not be left on after the prescribed duration, and the old one should be safely disposed of before applying a new one.

Why the other choices are incorrect:

B) Shave the client's lower leg for placement of the new patch.

This is incorrect because shaving the area is not necessary for placing a transdermal patch. In fact, shaving can irritate the skin and create microscopic cuts that might allow the medication to be absorbed too quickly. It is recommended to apply the patch to clean, dry, and hairless skin, but shaving should be avoided to prevent skin irritation.

C) Keep the existing patch on and place the new patch in a different location.

This is incorrect because the existing patch should be removed before placing a new one. Leaving the old patch on while applying a new one could result in overmedication or inconsistent dosing, and it increases the risk of side effects.

D) Discard the old patch and apply a new one in the same location.

This is incorrect because while the old patch should be discarded, it is important to apply the new patch to a different area of the skin to avoid irritation or buildup of medication in the same spot. This prevents localized skin reactions and ensures effective medication absorption.

Summary:

Fold the existing patch on itself and dispose of it in a childproof container, which ensures safe disposal and prevents accidental exposure. The other options either involve incorrect practices or unnecessary steps for patch application.