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A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? -The client uses a wool blanket on their bed. -The client identifies the location of a fire extinguisher. ...

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  • May 23, 2024
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  • 2023/2024
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ATI RN Fundamentals Online Practice A question with correct answer
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
-The client uses a wool blanket on their bed. -The client identifies the location of a fire extinguisher.
-The client stores an extra oxygen tank on its side under their bed. -The client has a weekly inspection checklist for oxygen equipment. Correct Answer - The client identifies the location of a fire extinguisher. -The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.
A nurse is teaching a client and his family how to care for the client's tracheostomy
at home. Which of the following instructions should the nurse include in the teaching?
-Remove the outer cannula cautiously for routine cleaning. -Use tracheostomy covers when outdoors. -Use sterile techniques when performing tracheostomy care at home.
-Cleanse irritated skin with full-strength hydrogen peroxide. Correct Answer - Use tracheostomy covers when outdoors. -Tracheostomy covers protect the client airway from cold air, dust, and other airborne particles. A home health nurse is performing a follow-up visit for a client who has a gastronomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of diarrhea?
-The client is receiving formula at room temperature.
-The feedings infuse at a slow, continuous drip over 8 hr each night. -The clients caregiver washes out the feeding bag with warm water once every 24 hr.
-The clients caregiver flushes the tubing with water before and after administering medications. Correct Answer - The clients caregiver washes out the feeding bag with warm water once every 24 hr.
-Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the clients caregiver to avoid future contamination.
A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the client's pain?
-Is your pain constant or intermittent?
-What would you rate your pain as, on a scale of 0 to 10?
-Does the pain radiate?
-Is your pain sharp or dull? Correct Answer - "Is your pain sharp or dull?"
-Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is talking with an older client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?
-You would have so much more time to spend with your family. -You should consider getting a part-time job or doing volunteer work. -Lets talk about how the change in your job status will affect you. -Why wouldn't you want to retire and relax? Correct Answer - "Lets talk about how the change in your job status will affect you."
-This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? -Discuss risk factors for colon cancer. -Focus teaching on what the client will need to do in the future to manage his illness. -Provide the client with written information about the phases of loss and grief. -Reassure the client that this is an expected response to grief. Correct Answer - Reassure the client that this is an expected response to grief. -During the anger stage of the clients psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.
A nurse on a medical-surgical unit is caring for a client who has a new prescription
for wrist restrains. Which of the following actions should the nurse take? -Pad the clients wrists before applying the restrains. -Evaluate the client's circulation every 8 hr after application. -Remove the restraints every 4 hr to evaluate the clients status.
-Secure the restraint ties to the bed's side rails. Correct Answer - Pad the clients wrists before applying restrains.
- The use of restraints without padding can abrade the clients skin, resulting in injury.

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