Ati nur 105 fundamentals exam

Ati nur 105 fundamentals exam

Total Questions : 49

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Question 1: View

A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight?

Explanation

A. Waist circumference alone is not a direct measure of overweight or obesity but can be an indicator of abdominal fat, which is a risk factor for health issues. For males, a waist circumference greater than 102 cm (40 in) is generally considered an increased risk for health problems related to obesity.
B. Body Mass Index (BMI) is a commonly used measure to classify weight status. For adults, a BMI of 24 falls within the "normal weight" range, which is between 18.5 and 24.9. This client is not classified as overweight, as the threshold for overweight is a BMI of 25 or higher.
C. For females, a waist circumference greater than 88 cm (35 in) is often considered an increased risk for health issues related to obesity. At 40 inches (101.6 cm), this female client exceeds the threshold and may be at higher risk for obesity-related health problems, though this does not strictly classify her as overweight based on BMI or waist circumference alone.
D. A BMI of 29 falls into the "overweight" category, which ranges from 25 to 29.9. Therefore, this male client is classified as overweight based on his BMI.


Question 2: View

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Explanation

A. Consuming hot cocoa, especially if it contains caffeine or sugar, is generally not advisable before bedtime. Caffeine is a stimulant that can interfere with the ability to fall asleep, and sugar can lead to disruptions in sleep. Even if the hot cocoa is caffeine-free, having a liquid right before bed can cause frequent awakenings during the night.
B. Alcohol can initially make a person feel drowsy, but it often disrupts sleep patterns later in the night, leading to poorer quality sleep. Reducing or eliminating alcohol consumption before bedtime can improve sleep quality and promote better rest.
C. While regular physical activity is beneficial for sleep, exercising too close to bedtime can actually be stimulating and make it harder to fall asleep. It is generally recommended to complete vigorous exercise at least 2-3 hours before going to bed to avoid interfering with sleep.
D. Muscle relaxation techniques, such as progressive muscle relaxation, are effective for reducing stress and improving sleep quality. However, performing these techniques in the afternoon is less beneficial compared to doing them closer to bedtime.


Question 3: View

A charge nurse is observing a newly-licensed nurse insert an Indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?

Explanation

A. Lubricating the catheter helps reduce friction and discomfort during insertion.
B. Sterile gloves help prevent the introduction of microorganisms into the urinary tract.
C. Securing the tubing to the client's upper thigh can lead to discomfort and increased risk of skin irritation. The tubing should be secured to the client's lower abdomen or inner thigh to prevent tension and potential complications.
D. Gently pulling on the catheter after inflating the balloon helps ensure that the balloon is fully inflated and properly positioned in the bladder.


Question 4: View

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Explanation

A. While holding the client’s arm might seem like a supportive action, it is not the most effective method to prevent a fall. If a client begins to fall, holding their arm could result in injury to either the client or the nurse, as it does not provide adequate control to prevent the fall. Instead, more proactive measures should be taken to safely manage the situation.
B. Assuming a narrow base of support (standing with feet close together) is actually less stable and can increase the risk of falling. To effectively prevent or manage a fall, the nurse should assume a wide base of support (feet apart) to enhance stability and balance.
C. If a fall is imminent and cannot be prevented, the best approach is to safely lower the client to the floor to minimize the risk of injury. The nurse should support the client’s body as they go down, guiding them gently to the floor to avoid a sudden impact. This technique helps reduce the potential for serious injuries such as fractures or head trauma.
D. Leaning the client toward the wall might provide temporary support but does not fully address the risk of a fall. It may also place the client in an awkward or unsafe position. The best approach is to take more direct action to prevent the fall or safely lower the client if the fall is unavoidable.


Question 5: View

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client's next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives?

Explanation

A. While Lactated Ringer's is often used for fluid resuscitation, it doesn't contain the necessary nutrients to replace TPN. It can lead to electrolyte imbalances and other complications if used for extended periods.
B. While Dextrose 10% provides calories, it lacks essential amino acids, electrolytes, and other nutrients found in TPN. Prolonged use can lead to imbalances and nutritional deficiencies.
C. Dextrose 5% in water is a commonly used IV fluid that can be administered temporarily while waiting for the next TPN container. It provides hydration and some calories, but it's important to monitor the client's glucose levels closely.
D. While 0.9% sodium chloride (normal saline) is used for fluid replacement, it can lead to hypernatremia (excess sodium) if used for extended periods, especially in clients receiving TPN.


Question 6: View

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Explanation

A. The supine position increases the risk of aspiration, where food or liquid could enter the airway and potentially cause aspiration pneumonia. To minimize this risk, the client should be positioned in a semi- Fowler’s position (head of the bed elevated at 30-45 degrees) during feedings.
B. Aspirating gastric residual volumes is a standard practice to check for proper digestion and tolerance of the feeding. Generally, a residual of up to 250-500 mL can be acceptable depending on institutional policy and client condition. This action does not necessarily require intervention unless specific guidelines indicate otherwise.
C. Irrigating the NG tube with tap water is a common practice to ensure the tube remains patent and to help clear any residual feeding material from the tube. Tap water is generally considered acceptable for this purpose, though some facilities may use sterile or distilled water to avoid any potential infections.
D. Administering the feeding through a syringe barrel by gravity is a standard method for intermittent tube feedings. This technique allows the feeding to flow slowly into the stomach without excessive pressure, which can help prevent complications such as nausea or cramping.


Question 7: View

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

Explanation

A. Drinking adequate fluids is essential during pregnancy to support overall health and amniotic fluid levels. A general recommendation is to drink about 2 to 3 liters (8-12 cups) of fluids per day. This includes water, and sometimes other beverages and soups.
B. It is well-established that alcohol consumption during pregnancy is harmful and can lead to serious conditions such as fetal alcohol syndrome. The advice to avoid alcohol entirely during pregnancy is accurate and reflects current medical guidelines.
C. Moderate caffeine consumption is generally considered acceptable during pregnancy. Most guidelines suggest limiting caffeine intake to about 200-300 milligrams per day (equivalent to about 1-2 cups of coffee). This advice is consistent with current recommendations.
D. The recommended daily calcium intake during pregnancy is typically around 1,000 milligrams per day for most pregnant women. An intake of 1,500 milligrams per day is higher than the usual recommendation and may not be necessary unless specifically advised by a healthcare provider for individual circumstances.


Question 8: View

A nurse is caring for a client who is taking sucralfate. Which of the following outcomes indicates a therapeutic effect of the medication?

Explanation

A. Sucralfate acts locally on the gastrointestinal mucosa by forming a protective barrier that adheres to ulcers and erosions. This barrier helps protect the tissue from stomach acid and promotes healing. As a result, the therapeutic effect of sucralfate often includes relief from gastrointestinal pain associated with ulcers and erosions.
B. Sucralfate does not directly treat Helicobacter pylori, a bacterium often associated with peptic ulcers. The treatment for H. pylori usually involves a combination of antibiotics and acid-reducing medications such as proton pump inhibitors (PPIs) or H2-receptor antagonists.
C. Sucralfate does not have a role in preventing opportunistic infections. It is specifically used to protect and heal the gastrointestinal lining, not to influence immune function or infection risk.
D. Sucralfate does not affect vision. It is used to treat gastrointestinal issues, not ocular conditions. Improvement of impaired vision is not related to the therapeutic effect of sucralfate.


Question 9: View

A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?

Explanation

A. Vitamin C significantly enhances the absorption of non-heme iron (the type of iron found in plant- based foods) by reducing iron to a more absorbable form and forming a complex with it that facilitates absorption in the intestines. Consuming foods rich in vitamin C, such as citrus fruits, strawberries, or bell peppers, along with iron-rich foods, can improve iron absorption.
B. While fiber is an important component of a healthy diet, it can inhibit iron absorption. High-fiber foods may bind with iron and reduce its bioavailability. For optimal iron absorption, it's advisable to consume high-fiber foods separately from iron-rich meals or to ensure a balanced intake.
C. Vitamin A is essential for various bodily functions, including vision and immune function. While it does not directly enhance iron absorption, it plays a role in overall health and can influence iron metabolism. However, its role in iron absorption is less direct compared to vitamin C.
D. Oxalates, found in foods like spinach, rhubarb, and certain nuts, can bind to iron and inhibit its absorption. They form insoluble complexes with iron, making it less available for absorption in the intestines.


Question 10: View

A nurse is providing teaching to a client who is pregnant and is vegan. The nurse should instruct the client that which of the following foods is a reliable source of Vitamin B12?

Explanation

A. Tempeh is a fermented soybean product, but it's not a reliable source of vitamin B12. While it can contain some vitamin B12, the amount can vary depending on the production process.
B. Sunflower margarine is a plant-based product and does not contain vitamin B12.
C. Sea vegetables can contain some vitamin B12, but the amount is often unreliable and can vary depending on the type of sea vegetable and where it was grown.
D. Algae is the most reliable plant-based source of vitamin B12. It's a common ingredient in many vegan vitamin B12 supplements and fortified foods.


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