RN-ATI-Fundamentals-of-Nursing-2023-2024

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urses' Notes 0900:
Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12~O Ib)in 3 months.
0930:Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted.

For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn’s disease.

  • A. Fever
  • B. Steatorrhea
  • C. Anemia
  • D. Weight loss
  • E. Diarrhea
Correct Answer: A, B, C, D

Rationale: To determine which assessment findings are consistent with ulcerative colitis, diverticulitis, or Crohn's disease, we need to analyze the characteristics of each condition.

1. Fever : This finding can be seen in all three conditions, but it is more commonly associated with Crohn's disease due to the inflammatory nature of the disease.

2. Steatorrhea (B): This is a common symptom of Crohn's disease due to malabsorption issues, making it a key indicator for this condition.

3. Anemia (C): Anemia is a common complication of inflammatory bowel diseases like ulcerative colitis and Crohn's disease, often related to chronic inflammation and blood loss.

4. Weight loss (D): This is a common feature of all three conditions due to malabsorption, decreased appetite, and chronic inflammation.

Therefore, the correct answer is A, B, C, D as these findings are consistent with all three conditions. Diarrhea (E

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A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

  • A. Suggest rinsing his mouth with an alcohol-based mouthwash
  • B. Provide humidification of the room air
  • C. Offer the client saltine crackers between meals
  • D. Instruct the client on the use of esophageal speech
Correct Answer: B

Rationale: The correct answer is B: Provide humidification of the room air. Xerostomia is dry mouth often caused by radiation therapy, which can lead to discomfort and difficulty swallowing. Humidifying the room air can help alleviate dryness, making it easier for the client to breathe and swallow. Alcohol-based mouthwash (A) can worsen dryness due to its drying effect. Saltine crackers (C) can be difficult to swallow with a dry mouth. Esophageal speech (D) is not relevant to xerostomia.

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

  • A. A client who is scheduled for a procedure in 1 hr.
  • B. A client who received a pain medication 30 min ago for postoperative pain.
  • C. A client who was just given a glass of orange juice for a low blood glucose level.
  • D. A client who has 100 mL of fluid remaining in his IV bag.
Correct Answer: C

Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.

Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.

A nurse is planning to reposition a client who had a stroke. Which of the following actions should the nurse take?

  • A. Evaluate the client's ability to help with repositioning.
  • B. Reposition the client without the use of assistive devices.
  • C. Raise the side rails on both sides of the client's bed during repositioning.
  • D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A

Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is essential as it considers the client's level of participation and promotes independence. Assessing the client's ability to assist ensures safety and prevents injury during repositioning. It also promotes client-centered care by involving the client in their own care.

Choice B is incorrect because repositioning without assistive devices may not be safe or effective, especially for a stroke client who may have limited mobility.

Choice C is incorrect because raising the side rails does not address the client's ability to help with repositioning. It may provide some safety measures but does not actively involve the client in the process.

Choice D is incorrect as discussing preferences for a repositioning schedule does not address the immediate need to evaluate the client's ability to assist with repositioning.

Overall, choice A is the most appropriate as it prioritizes the client's safety, independence, and active participation in their care.

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

  • A. Initiate a requisition for a replacement CPM device.
  • B. Report the defect to the equipment maintenance staff.
  • C. Remove the device from the room.
  • D. Ensure the device inspection sticker is current.
Correct Answer: C

Rationale: The correct action the nurse should take first is to remove the device from the room (Choice C). This is crucial because a frayed electrical cord poses a significant safety risk, potentially leading to electric shock or fire hazard. By removing the device from the room, the nurse ensures that the client and others are not exposed to the danger posed by the damaged cord. Initiating a requisition for a replacement device (Choice A) can be done after ensuring immediate safety. Reporting the defect to equipment maintenance staff (Choice B) is important, but it is secondary to removing the device from the room. Ensuring the device inspection sticker is current (Choice D) is not the priority when there is a clear safety issue present.

The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.

  • A. Limit alcohol intake to 0 oz per day.
  • B. Keep daily fat intake to less than 35%.
  • C. Administer an anti-obesity medication.
  • D. Administer an antihypertensive medication.
  • E. Limit foods high in potassium.
Correct Answer: A, B, D

Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.