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OHBOV02 Verpleegkundige zorg aan mensen met een chronische ziekte, T.48930 $18.99   Añadir al carrito
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OHBOV02 Verpleegkundige zorg aan mensen met een chronische ziekte, T.48930
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numbers or a list of objects How to test a client's recent memory - ANSWER Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission The client is able to open their eyes and respond but is drowsy and fall...

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  • 9 de agosto de 2024
  • 34
  • 2024/2025
  • Examen
  • Preguntas y respuestas

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  • ohbov02 verpleegkundige zorg aan mensen met een
  • ohbov02 verpleegkundige zorg aan mensen met ee
  • ohbov02 verpleegkundige zorg aan mensen met ee

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  • ATI FADERM WITH AND
  • ATI FADERM WITH AND

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ATI Comprehensive Online
Practice 2019 with correct
questions and answers
2024/2025


A. Withdraw the catheter if the client begins coughing

B. Apply suction for 10 seconds

C. Advance the catheter 2 cm (0.8 in) after resistance is met

D. Use medical asepsis when performing the procedure - ANSWER ✓✓✓CORRECT: Apply
suction for 10 seconds

Rationale: The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss.



Rationale A: Suctioning can initiate the cough reflex as it opens the airway further and allows for
more effective removal of mucus.



Rationale C: Once resistance is met, the nurse should withdraw the catheter 1 to 2 cm (0.4 in to
0.8 in) to prevent damaging bronchial tissues.

,Rationale D: The nurse should use surgical asepsis when suctioning a newly created
tracheostomy to reduce the risk for infection.

A nurse is performing tracheostomy care for a client who is postoperative following a
laryngectomy. Which of the following actions should the nurse take when suctioning the client's
airway?

A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client
who has an extensive burn injury. Which of the following information should the nurse include?

A. "This type of nutrition is more effective than eating by mouth.:

B. "You will receive fingersticks for blood glucose testing."

C. "TPN is a way to provide vitamins and minerals without increased calories."

D. "Taking TPN can increase the risk of developing a latex allergy." - ANSWER ✓✓✓ANSWER:
"You will receive fingersticks for blood glucose testing."

Rationale: A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the
TPN solution. Therefore, the client will require blood glucose monitoring.



Rationale A: The client should receive oral or enteral nutrition whenever possible because it
enhances the immune system and maintains intestinal motility. However, the client should
receive TPN when nutritional needs are greater than oral or enteral nutrition can provide, such
as in a client who has burn injuries.



Rationale C: TPN provides calories to clients who are unable to eat or who do not have a
functioning gastrointestinal tract. A client who has a burn injury is in a hypermetabolic state and
requires additional calories, carbohydrates, proteins, and fats.



Rationale D: The nurse should check the client for an egg allergy, because this can result in an
intolerance of the lipid solution and many lipids are composed of egg phospholipids.



A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-
sided weakness. Which of the following actions should the nurse take first?

A. Ask a social worker to identify the client's insurance eligibility for rehabilitation services.

B. Request a referral for the client to receive physical therapy.

,C. Arrange for the delivery of prescribed medications to the client's home.

D. Provide the client with a list of community resources. - ANSWER ✓✓✓ANSWER: Request a
referral for the client to receive physical therapy.

Rationale: The greatest risk to this client is injury from falls. Therefore, the first action the nurse
should take is to request a referral for physical therapy.



Rationale A: The nurse should ask a social worker to determine the client's insurance eligibility
for rehabilitation services to enable continuity of care closer to the time of discharge. However,
there is another action the nurse should take first.



Rationale C: The nurse should arrange for the delivery of prescribed medications to the client's
home to ensure the client has the medications available. However, there is another action the
nurse should take first.



Rationale D: The nurse should provide the client with a list of community resources once the
health care team establishes which services will be used for rehabilitation. However, there is
another action the nurse should take first.



A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the
following actions should the nurse plan to take?

A. Keep the client resting in bed.

B. Ask the client to restate directions.

C. Clear objects from the client's walking area.

D. Evaluate the client's ability to swallow. - ANSWER ✓✓✓ANSWER: Clear objects form the
client's walking area.

Rationale: The nurse should plan to clear objects from the client's walking area because CN II is
the optic nerve and a deficit can result in visual impairment which can lead to falls.



Rationale A: A client who has a CN II deficit does not require bed rest but should have
assistance when out of bed.

, Rationale B: The nurse should plan to ask clients to restate directions if they have a CN VIII
deficit because CN VIII affects hearing.



Rationale D: The nurse should plan to evaluate the swallowing ability of clients who have a CN
IX deficit because it can impair swallowing.



A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis.
Which of the following instructions should the nurse include? SATA

A. "A speech pathologist will be performing a swallowing study for you."

B. "You should rest before eating a meal."

C. "You should restrict foods that are high in vitamin D."

D. "Reduce your intake of dietary fiber."

E. "Thicken your beverages before drinking." - ANSWER ✓✓✓ANSWER: A, B, E

Rationale A: The nurse should instruct the client that a swallowing study will be performed to
determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of
multiple sclerosis.



Rationale B: The nurse should encourage the client to rest before each meal. Clients who have
multiple sclerosis often report weakness and are easily fatigued.



Rationale C: The nurse should instruct the client to maintain adequate vitamin D levels, because
vitamin D deficiency is a risk factor for multiple sclerosis.



Rationale D: The nurse should instruct the client to increase dietary fiber and fluids to decrease
the risk of constipation, which is a manifestation of multiple sclerosis.



Rationale E: The nurse should instruct the client that liquids should be thickened to reduce the
risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis.

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