ATI RN
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1. A client has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Assign an assistive personnel to feed the client.
- B. Explain to the client that their tray is here and guide their hands to it.
- C. Describe to the client the location of the food on the tray.
- D. Ask the client if they would prefer a liquid diet.
Correct answer: C
Rationale: When a client has bilateral eye patches, promoting independence in eating is crucial to maintain dignity and autonomy. Describing the location of the food on the tray enables the client to locate and feed themselves. Assigning assistive personnel to feed the client (Choice A) takes away their independence. Merely informing the client that the tray is here and guiding their hands to it (Choice B) does not empower the client to eat independently. Asking if the client prefers a liquid diet (Choice D) is not directly addressing the client's ability to independently eat the current meal.
2. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develop postoperatively?
- A. Cardiac arrest C. Respiratory failure
- B. Dyspnea D. Tetany
- C.
- D.
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
3. A client is receiving education from a nurse regarding the dietary changes needed for weight loss. Which of the following actions should the nurse perform first?
- A. Educate the client about daily caloric requirements.
- B. Determine the client’s daily caloric intake.
- C. Provide the client with meal planning information.
- D. Show the client how to identify the fat content of packaged foods.
Correct answer: B
Rationale: The correct answer is to determine the client’s daily caloric intake first. This step is crucial in understanding the client's current dietary habits and establishing a baseline for creating an effective weight loss plan. Educating the client about daily caloric requirements (Choice A) can only be done effectively after knowing the client's current intake. Providing meal planning information (Choice C) and teaching the client how to identify fat content in foods (Choice D) come after determining the baseline caloric intake to tailor the plan accordingly.
4. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?
- A. Instruct the client to observe strict bed rest
- B. Check for epidural catheter drainage
- C. Administer analgesia through the epidural catheter as prescribed
- D. Assess respiratory rate carefully
Correct answer: D
Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.
5. A nurse is teaching a parent about appropriate snack choices for her 9-month-old infant. Which of the following food choices should the nurse recommend?
- A. Skim milk
- B. Unsalted popcorn
- C. Graham crackers
- D. Raw carrots
Correct answer: C
Rationale: Graham crackers are an appropriate snack choice for a 9-month-old infant due to their texture and ease of consumption. Skim milk (Choice A) is not recommended for infants under 1 year old due to the potential risk of developing milk allergies. Unsalted popcorn (Choice B) can be a choking hazard for infants. Raw carrots (Choice D) are a potential choking hazard for a 9-month-old infant and may be difficult for them to chew and digest.
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