while the client has pulse oximeter on his fingertip you notice that the sunlight is shining on the area where the oximeter is your action will be to
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Nursing Elites

ATI RN

Nutrition ATI Test

1. 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:

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.

2. What is your estimate of the population of pregnant woman needing tetanus toxoid vaccination?

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

3. Which meal should be removed for a client taking warfarin?

Correct answer: C

Rationale: The correct meal to remove for a client taking warfarin is the 'Ham and cheese sandwich.' Ham is high in vitamin K, which can interfere with the effectiveness of warfarin, a medication that works by decreasing the clotting ability of the blood. Vitamin K can counteract the effects of warfarin by promoting blood clotting. Choices A, B, and D do not contain high amounts of vitamin K and are therefore safer options for individuals taking warfarin.

4. Which nursing diagnosis has nutritional implications?

Correct answer: A

Rationale: Impaired dentition affects a patient's ability to chew and consume a variety of foods, leading to potential nutritional deficiencies and malnutrition.

5. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

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