ATI RN
Nutrition ATI Test
1. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:
- A. Take the blood pressure reading on both arms for comparison
- B. Listen to and identify the phases of Korotkoff sounds
- C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
- D. Observe procedures for infection control
Correct answer: B
Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.
2. Which of the following treatments is not recommended for a child classified with no dehydration?
- A. Administering 1,000 ml to 1,400 ml within 4 hours
- B. Continuing feeding
- C. Allowing the child to take as much fluid as he wants
- D. Returning the child to the doctor if the condition worsens
Correct answer: B
Rationale: The correct answer is B. Continuing feeding is a recommended treatment for a child classified with no dehydration. This helps maintain the child's nutritional status and supports recovery. Options A, C, and D are appropriate interventions for a child with no dehydration. Option A ensures adequate fluid intake, option C promotes hydration, and option D ensures appropriate follow-up if the condition worsens.
3. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:
- A. Set and turn on the alarm of the oximeter
- B. Do nothing since there is no identified problem
- C. Cover the fingertip sensor with a towel or bedsheet
- D. Change the location of the sensor every four hours
Correct answer: B
Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.
4. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:
- A. perfusion
- B. locomotion
- C. respiration
- D. mentation
Correct answer: D
Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.
5. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You, as the RN, will make sure that the family knows to:
- A. offer pureed foods
- B. offer soft foods for a week to minimize discomfort while swallowing
- C. supplement his diet with Vitamin C-rich foods to enhance healing
- D. offer clear liquids for 3 days to prevent irritation
Correct answer: B
Rationale: After tonsillectomy and adenoidectomy, it is crucial to provide soft foods for a week to minimize discomfort while swallowing. This helps prevent irritation to the surgical site and allows for easier healing. Offering pureed foods (Choice A) may not be necessary as soft foods are usually sufficient. While Vitamin C is beneficial for healing, it is not necessary to supplement it immediately after surgery with Vitamin C-rich juices (Choice C). Clear liquids are typically recommended before surgery and not after, as the focus shifts to soft foods to aid in recovery, making Choice D incorrect.
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