ATI RN
Multi Dimensional Care | Final Exam
1. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
- A. The UAP puts shoes on the client
- B. The UAP removes floor rugs and loose objects from the path
- C. The UAP walks to the side and slightly in front of the client
- D. The UAP uses a transfer (gait) belt
Correct answer: C
Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
2. Which of the following vascular system changes result from aging?
- A. Increased peripheral resistance of the blood vessels
- B. Decreased blood flow
- C. Increased workload of the left ventricle
- D. All of the above
Correct answer: D
Rationale: As individuals age, various changes occur in the vascular system. These changes include increased peripheral resistance of the blood vessels, decreased blood flow, and an increased workload of the left ventricle. Therefore, all the listed changes result from aging, making option D, 'All of the above,' the correct answer.
3. The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?
- A. Send the child to his or her room if the child has one.
- B. A general rule for length of time is 1 hour per year of age.
- C. Select an area that is safe and nonstimulating, such as a hallway.
- D. If the child cries, refuses, or is more disruptive, try another approach.
Correct answer: C
Rationale: Time-outs should be in a safe, nonstimulating area, with the length typically being 1 minute per year of the child's age, not 1 hour.
4. During a home visit, a nurse sees a client with COPD receiving oxygen at 2 L/min through a nasal cannula. The client reports difficulty breathing. What is the priority nursing action at this time?
- A. Increase the oxygen flow to 3 L/min.
- B. Evaluate the client's respiratory status.
- C. Call emergency services for the client.
- D. Instruct the client to cough and clear secretions.
Correct answer: Evaluate the client's respiratory status.
Rationale: The priority nursing action in this situation is to evaluate the client's respiratory status. When a client with COPD on oxygen therapy experiences difficulty breathing, the nurse should first assess the client's respiratory status to determine the severity of the situation. Increasing the oxygen flow without proper assessment can be harmful if not clinically indicated. While calling emergency services may eventually be necessary, it should not be the immediate action without assessing the client first. Instructing the client to cough and clear secretions is not appropriate as the nurse needs to evaluate the respiratory status before proceeding with interventions.
5. A healthcare professional is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the healthcare professional administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 4 mL
- B. 6 mL
- C. 10 mL
- D. 5.5 mL
Correct answer: 4 mL
Rationale: To calculate the mL of albuterol syrup needed per dose, first, determine how many milligrams are in the prescribed dose: 1.6 mg. Next, set up a proportion to find the equivalent mL for 1.6 mg using the given concentration of 2 mg/5mL. The calculation is: (1.6 mg x 5 mL) / 2 mg = 4 mL. Therefore, the correct answer is 4 mL to administer per dose.
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