Ati nurs100102 fundamentals retake

Question 1: View

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

A. I'll use each cleansing wipe twice. B. I'll urinate a little then stop. C. I'll clean the inside of the container with a wipe. D. I'll use the cleansing wipe from front to back.

Explanation

A reason:

Using each cleansing wipe twice is not correct procedure. Cleansing wipes should be used once and then discarded to maintain cleanliness and avoid contamination of the sample.

B reason:

Urinating a little and then stopping is part of the procedure, but the client should also understand the importance of cleansing. While stopping the stream initially is correct, it is not sufficient alone without proper cleansing.

C reason:

Cleaning the inside of the container with a wipe is incorrect. The inside of the container should remain sterile, and cleaning it with a wipe could introduce contaminants. The container is designed to be clean and sterile inside.

D reason:

Using the cleansing wipe from front to back is correct. This method ensures that bacteria from the anal area do not contaminate the urethral opening, which helps to collect a clean midstream urine sample.

Question 2: View

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

A. Remove all metal necklaces. B. Take several shallow breaths during the procedure. C. Do not eat or drink anything the morning of the test. D. Expect minor discomfort after the procedure.

Explanation

A reason:

Removing all metal necklaces is correct because metal objects can interfere with the x-ray imaging. Metal can cause artifacts on the x-ray, making it difficult to interpret the results accurately. Therefore, clients are advised to remove any metal jewelry or accessories before the procedure.

B reason:

Taking several shallow breaths during the procedure is not correct. Clients are usually instructed to take a deep breath and hold it for a few seconds while the x-ray is being taken. This helps to get a clear image of the chest.

C reason:

Not eating or drinking anything the morning of the test is not necessary for a chest x-ray. This instruction is more relevant for certain other tests, such as blood tests or imaging studies requiring contrast. For a chest x-ray, there are no such restrictions.

D reason:

Expecting minor discomfort after the procedure is incorrect. A chest x-ray is a non-invasive and painless procedure. Patients typically do not experience any discomfort afterward.

Question 3: View

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

A. Remove all metal necklaces. B. Take several shallow breaths during the procedure. C. Do not eat or drink anything the morning of the test. D. Expect minor discomfort after the procedure.

Explanation

A reason:

Removing all metal necklaces is correct because metal objects can interfere with the x-ray imaging. Metal can cause artifacts on the x-ray, making it difficult to interpret the results accurately. Therefore, clients are advised to remove any metal jewelry or accessories before the procedure.

B reason:

Taking several shallow breaths during the procedure is not correct. Clients are usually instructed to take a deep breath and hold it for a few seconds while the x-ray is being taken. This helps to get a clear image of the chest.

C reason:

Not eating or drinking anything the morning of the test is not necessary for a chest x-ray. This instruction is more relevant for certain other tests, such as blood tests or imaging studies requiring contrast. For a chest x-ray, there are no such restrictions.

D reason:

Expecting minor discomfort after the procedure is incorrect. A chest x-ray is a non-invasive and painless procedure. Patients typically do not experience any discomfort afterward.

Question 4: View

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

A. Administer the medication. B. Reposition the client. C. Review the effects of the pain medication. D. Determine the location of the pain.

Explanation

A reason:

Using each cleansing wipe twice is not correct procedure. Cleansing wipes should be used once and then discarded to maintain cleanliness and avoid contamination of the sample.

B reason:

Urinating a little and then stopping is part of the procedure, but the client should also understand the importance of cleansing. While stopping the stream initially is correct, it is not sufficient alone without proper cleansing.

C reason:

Cleaning the inside of the container with a wipe is incorrect. The inside of the container should remain sterile, and cleaning it with a wipe could introduce contaminants. The container is designed to be clean and sterile inside.

D reason:

Using the cleansing wipe from front to back is correct. This method ensures that bacteria from the anal area do not contaminate the urethral opening, which helps to collect a clean midstream urine sample.

Question 5: View

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

A. Hold the hands higher than the elbows. B. Rub hands and arms to dry. C. Adjust the water temperature to feel hot. D. Apply 4 to 5 ml of liquid soap to the hands.

Explanation

A reason:

Holding the hands higher than the elbows is incorrect. Hands should be held lower than the elbows during washing to allow water to flow from the cleanest to the dirtiest area and prevent recontamination.

B reason:

Rubbing hands and arms to dry is incorrect. Hands should be dried using a clean towel or air dryer. Rubbing can reintroduce bacteria and is not recommended.

C reason:

Adjusting the water temperature to feel hot is incorrect. Water should be warm, not hot, to avoid skin irritation and ensure effective hand hygiene.

D reason:

Applying 4 to 5 ml of liquid soap to the hands is correct. Using an adequate amount of soap ensures thorough cleaning and removal of germs and contaminants during hand washing.

Question 6: View

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

A. Partial-thickness skin loss B. Necrotic subcutaneous tissue C. Exposed bone D. Blood-filled blisters

Explanation

A reason:

Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, not stage 3. Stage 2 ulcers involve damage to the epidermis and part of the dermis but do not extend deeper into the subcutaneous tissue.

B reason:

Necrotic subcutaneous tissue is a hallmark of stage 3 pressure ulcers. At this stage, the ulcer extends through the full thickness of the skin and into the subcutaneous tissue, which may become necrotic. However, it does not involve bone, tendon, or muscle exposure.

C reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. Stage 4 ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, indicating deeper and more severe damage than a stage 3 ulcer.

D reason:

Blood-filled blisters are typically associated with deep tissue injury rather than stage 3 pressure ulcers. These blisters signal underlying tissue damage from sustained pressure, but they are not specific to stage 3.

Question 7: View

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A. Apply cornstarch to keep the skin dry B. Reposition the client every 3 hours C. Massage bony prominences to promote circulation D. Provide the client with a diet high in protein

Explanation

A reason:

Applying cornstarch to keep the skin dry is not recommended because it can lead to irritation and promote fungal growth. Instead, barrier creams or moisture-wicking products are more appropriate to maintain skin dryness and integrity.

B reason:

Repositioning the client every 3 hours is not frequent enough to effectively prevent skin breakdown in at-risk patients. The standard recommendation is to reposition the client every 2 hours to relieve pressure and reduce the risk of pressure ulcers.

C reason:

Massaging bony prominences is not advisable as it can cause additional trauma to the skin and underlying tissues, potentially worsening the risk of skin breakdown. Gentle repositioning and cushioning are more effective strategies.

D reason:

Providing the client with a diet high in protein is essential for maintaining skin integrity. Protein is vital for tissue repair and regeneration, and a high-protein diet supports overall skin health and resilience against breakdown.

Question 8: View

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

A. Make sure the room temperature is cool B. Provide music as an environmental distraction C. Inform the client that the provider will examine sensitive areas first D. Explain to the client what is about to happen

Explanation

A reason:

Making sure the room temperature is cool may not be comfortable for an older adult client, who may be more sensitive to cold. Ensuring a comfortable room temperature is important, but the focus should be on clear communication and patient comfort.

B reason:

Providing music as an environmental distraction can be helpful, but it is not the most critical action to take when preparing a client for an examination. Clear explanations and reassurance take precedence to ensure the client understands and feels comfortable with the process.

C reason:

Informing the client that the provider will examine sensitive areas first is not appropriate. Sensitive areas should generally be examined last to reduce the patient's anxiety and discomfort. It is more important to explain the examination sequence and provide reassurance.

D reason:

Explaining to the client what is about to happen is essential. Clear communication helps to alleviate anxiety, ensure cooperation, and build trust between the client and healthcare provider. It is crucial to provide a step-by-step explanation of the examination process.

Question 9: 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?

A. I will have a cup of hot cocoa immediately before bedtime B. I will walk briskly for 30 minutes before bedtime C. I will do my muscle relaxation techniques each afternoon D. I will no longer have a glass of wine before bedtime

Explanation

A reason:

Having a cup of hot cocoa immediately before bedtime is not advisable as it contains caffeine, which can interfere with sleep. Herbal teas or warm milk are better alternatives to promote relaxation and sleep.

B reason:

Walking briskly for 30 minutes before bedtime can be stimulating rather than relaxing. While regular exercise is beneficial for sleep, it is best performed earlier in the day. Exercise close to bedtime can increase alertness and make it harder to fall asleep.

C reason:

Doing muscle relaxation techniques each afternoon is beneficial, but the focus should be on practicing these techniques before bedtime to help wind down and prepare for sleep. Afternoon relaxation is good but not directly related to sleep promotion.

D reason:

Avoiding alcohol before bedtime is correct. Although alcohol may initially make one feel drowsy, it can disrupt sleep patterns and reduce sleep quality. Abstaining from alcohol before bed is a positive step toward improving sleep.

Question 10: View

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

A. Enlist help from another staff member B. Avoid movements that twist the spine C. Use a powered standing-assist lift D. Adjust the bed to an appropriate height

Explanation

A reason:

Enlisting help from another staff member is important for safety, but it is not the most specific intervention for this scenario. Using a powered lift ensures a safer and more controlled transfer process.

B reason:

Avoiding movements that twist the spine is good practice for the nurse's safety, but it does not directly address the client's need for assistance during the transfer. Proper lifting techniques are important, but mechanical assistance is preferable for this situation.

C reason:

Using a powered standing-assist lift is the best option. It helps the client who can partially bear weight to transfer safely and reduces the risk of injury to both the client and the nurse. This equipment is designed specifically for such transfers.

D reason:

Adjusting the bed to an appropriate height is a necessary step to facilitate the transfer, but it is not sufficient on its own. Using a lift in addition to adjusting the bed height ensures maximum safety and efficiency during the transfer process.