Exam (elaborations)
B260 Final ATI (1)
Exam of 12 pages for the course CPPS - at CPPS - (B260 Final ATI (1))
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B260 Final ATIB.
rationale: the nurse should perform hand hygiene prior to starting the procedure - ANS-A charge
nurse is teaching a new nurse how to initiate IV access on a client. Which of the following
actions by the new nurse indicates an understanding of the teaching?
A. shaves the selected insertion site w/ a razor prior to the procedure
B. washes hands w/ soap and water before the procedure
C. applies sterile gloves prior to inserting the IV catheter
D. applies the tourniquet 1 inch above the selected insertion site
B.
rationale: b/c nurses cannot measure pain objectively, it is standard practice to accept that pain
is what the client says it is and to intervene accordingly - ANS-A nurse is caring for a client who
is post-op. The nurse should base her pain management interventions primarily on which of the
following methods of determining the intensity of the client's pain?
A. vital sign management
B. the client's self-report of pain severity
C. visual observation for nonverbal signs of pain
D. the nature and invasiveness of the surgical procedure
A, B, D
rationale: a back rub promotes relaxation, relieves muscular tension, and decreases perception
of pain. relaxation or drooping of the shoulders is a positive response to the back rub - ANS-A
nurse provides a back massage as a palliative care measure to a client who is unconscious,
grimacing, and restless. Which of the following findings should the nurse identify as indicating a
therapeutic response? (Select all that apply.)
A. the shoulders droop
B. the facial muscles relax
C. the RR increases
D. the pulse is within the expected range
E. the client draws his legs into a fetal position
B.
rationale: following the death of a client who followed the Muslim faith, a Muslim of the same
gender must ritualistically wash and wrap the body - ANS-A nurse is observing an assistive
personnel performing postmortem care for a client who is Muslim. Which of the following actions
should prompt the nurse to intervene?
, A. leaves dentures in the mouth
B. prepares to cleanse the body
C. disconnects the cardiac monitor
D. removes soiled linens from the room
C.
rationale: anti-embolism stockings promote venous return from the legs, thus helping to prevent
venous thrombosis, also known as clot formation, and peripheral edema - ANS-A nurse is
providing pre-op teaching for a client who will undergo surgery. The nurse explains that the
client will wear anti-embolism stockings during and after the procedure. When the client asks
what the stockings do, which of the following responses should the nurse make?
A. "they protect your legs and heels from skin breakdown."
B. "they help keep you warm after your surgery."
C. "they improve your circulation to keep blood from pooling your legs."
D. "they make it easier for you to do leg exercises after your surgery."
B, D, E.
rationale: the basal metabolic rate is the energy a person needs for life-sustaining activities such
as breathing and maintaining circulation at rest. music therapy relaxes and calms, which would
decrease energy expenditure rather than increasing it - ANS-A nurse is providing palliative care
to a client whose partner asks why music therapy might help her. Which of the following
responses should the nurse make? (Select all that apply.)
A. "music therapy will increase her basal metabolic rate."
B. "music therapy can help her verbally express emotions."
C. "music therapy will improve her appetite and decrease the nausea."
D. "music therapy works as a distraction and can help alleviate her pain."
E. "music therapy can help facilitate movement in some clients who have mobility limitations."
B.
rationale: clients receiving palliative care are aware that the outcome is to prevent suffering and
provide the best possible quality of life - ANS-A nurse is caring for a client who has cancer and
is receiving palliative care. Which of the following statements by the client indicates they
understand this type of treatment?
A. "i am thinking of getting a second opinion."
B. "i am hoping this will limit my discomfort."
C. "this treatment should help me live a little longer."
D. "this is not working and i plan to stop treatment."
A.
rationale: asking the client to share his feelings encourages him to express the nature of his
feelings of anxiety. the nurse can begin by offering general leads. - ANS-A nurse is caring for a
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