which of the following action would be of highest priority with regards to the external shunt
Logo

Nursing Elites

ATI RN

ATI Nutrition Practice Test A 2019

1. Which of the following actions would be of highest priority with regards to the external shunt?

Correct answer: C: Heparinize the shunt daily

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

2. Reducing the amount of trans fat in the diet is an effective method of decreasing the risk of CHD. Which food is most likely a source of trans fat?

Correct answer: D

Rationale: The correct answer is D: potato chips. Potato chips, especially when fried in hydrogenated oils, are a common source of trans fats, which are linked to an increased risk of coronary heart disease (CHD). Hot dogs (choice A) can also contain trans fats if made with processed meats and added fats. Whole milk (choice B) and fatty fish (choice C) do not typically contain trans fats, making them less likely sources compared to potato chips.

3. During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?

Correct answer: D

Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.

4. A nurse is instructing teenage girls on the importance of adequate calcium intake throughout their life span to prevent complications. Which complication should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: Osteoporosis. Adequate calcium intake throughout life helps prevent osteoporosis, a condition characterized by weak and brittle bones, which is common in older adults. Goiter is caused by an iodine deficiency, not calcium. Heart disease is more related to factors like cholesterol and blood pressure. Dental caries are primarily influenced by oral hygiene and sugar intake, not just calcium.

5. Which nursing diagnosis is a priority for clients with Borderline personality disorder?

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.

Similar Questions

Which food is a reliable source of B12 for a pregnant vegan client?
Which enzyme is most essential for hydrolyzing large protein molecules?
What physiologic role does calcium play in the body?
While a team effort is necessary in the operating room (OR) for efficient and quality patient care delivery, the number of people in the room should be limited for infection control purposes. Which roles comprise this team?
To prevent recurrent attacks on client with glomerulonephritis, the nurse instructs the client to:

Access More Features

ATI RN Basic
$69.99/ 30 days

ATI RN Premium
$149.99/ 90 days

Other Courses