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Custom Sp23 N144 FINAL
ATI Custom Sp23 N144 FINAL
Total Questions : 60
Showing 10 questions Sign up for moreA charge nurse is providing an inservice for staff nurses on the use of new IV pumps.
Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment?
Explanation
Allowing time during the workday when each nurse can demonstrate proficiency is the best way to evaluate staff competency with the new equipment. This method ensures that the nurses can perform the skills correctly and safely under the charge nurse’s supervision and feedback.
Choice A is wrong because verbally questioning the staff about the new equipment does not assess their practical skills or ability to use the equipment correctly.
Choice B is wrong because requiring each nurse to take a written examination about the new equipment does not assess their hands-on skills or ability to troubleshoot problems with the equipment.
Choice D is wrong because asking each nurse to read the procedure and sign a form acknowledging competency does not verify that the nurses have understood the procedure or can apply it in practice.
It also relies on the nurses’ honesty and self-assessment, which may not be accurate or reliable.
A nurse is preparing to administer a medication to a client.
Which of the following actions by the nurse demonstrates advocacy for client rights?
Explanation
This demonstrates advocacy for client rights because it respects the client’s autonomy, dignity, and preferences. It also helps the client to make informed decisions about their own health.
Choice B is wrong because telling the client that refusal of the medication is considered noncompliance is coercive and violates the client’s right to refuse treatment.
It also does not address the client’s reasons for refusing the medication or provide any information or education.
Choice C is wrong because informing the client that the medication is the same as taken at home is not enough to ensure that the client understands the purpose, benefits, and risks of the medication.
It also does not verify that the client is taking the medication correctly at home or that there are no changes in the dosage or frequency.
Choice D is wrong because insisting the client takes the prescribed medications is also coercive and violates the client’s right to refuse treatment.
It also does not respect the client’s autonomy, dignity, and preferences.
It may also cause harm to the client if they have an allergy, intolerance, or contraindication to the medication.
Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice that requires nurses to protect and uphold their patients’ rights, values, and interests.
Which thermoregulatory condition is an elderly person most at risk for?
Explanation
Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased
shiver reflex, and lower immunity. They also tend to have a lower body temperature and may not develop fevers when they contract a viral or bacterial illness.
Choice B. Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).
Choice C. Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F).
Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.
Choice D. Malignant hyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants.
It is not related to thermoregulation in elderly people.
Question 5.
A client has a history of gastric bypass surgery within the past year. She presents to her primary care office for a check-up and states she has been troubled by several seemingly unrelated ailments: a sore tongue, tingling in her fingers, and “almost” falling several times due to lack of balance. The nurse notes that she is pale and slightly tachycardic.
Which type of anemia does the nurse suspect?
Explanation
This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.
Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy.
Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.
Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells.
It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.
Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth.
It can have many causes, such as blood loss, infection, inflammation, or chronic disease.
It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.
The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?
Explanation
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.
The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
Choice B is wrong because it is not a goal statement, but an intervention.
A goal statement should describe the expected outcome of the intervention, not the intervention itself.
Choice D is wrong because it is not measurable or time-bound.
A goal statement should have a clear indicator of how and when the outcome will be achieved.
The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
Explanation
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.
It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.
Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:
Explanation
Some of the symptoms of heat stroke are:
• High body temperature of 104 F (40 C) or higher
• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma
• Lack of sweating despite the heat
• Red, hot and dry skin
• Rapid and strong pulse
• Throbbing headach
• Nausea and vomiting
Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.
Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.
Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.
Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.
A nurse is preparing an in-service presentation about preventing health care associated infections (HAIs).
The nurse should include which of the following as a common cause of these infections?
Explanation
Urinary catheterization is a common cause of health care-associated infections (HAIs), which are infections that patients get while receiving medical treatment in a health care facility. Urinary catheterization involves inserting a tube into the bladder to drain urine, which can introduce bacteria into the urinary tract and cause infections.
Choice B is wrong because malnutrition is not a direct cause of HAIs, although it can weaken the immune system and increase the risk of infections.
Choice C is wrong because multiple caregivers are not a direct cause of HAIs, although they can increase the exposure to different pathogens and cross contamination if they do not follow proper hygiene and infection control practices.
Choice D is wrong because chlorhexidine washes are not a cause of HAIs, but rather a preventive measure to reduce the risk of HAIs by disinfecting the skin and mucous membranes.
An elderly man fell during his hospitalization and has died from a head injury sustained in the fall.
What is the role of the risk manager in this situation?
Explanation
The role of the risk manager is to identify and analyze the factors that contributed to the adverse event and to implement strategies to prevent or reduce the likelihood of recurrence. The risk manager is not concerned with assigning blame or protecting the staff from litigation, but rather with improving the quality and safety of care.
Choice A is wrong because it implies a punitive approach that does not address the underlying system issues.
Choice B is wrong because it suggests a defensive attitude that does not foster a culture of learning and improvement.
Choice D is wrong because it assumes that the nurses were not aware of the patient’s fall risk, which may not be the case.
The risk manager should investigate all aspects of the situation, including the communication and documentation of the patient’s fall risk assessment and interventions.
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