Review ATI_Custom_Custom_Elisabet_Perez_NUR1000D_Midterm_Summer_23

Exam Review

ATI_Custom_Custom_Elisabet_Perez_NUR1000D_Midterm_Summer_23_EVE

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Total Questions : 71

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Question 1:

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

A. Restrict the client's fluid intake to less than 2 L/day. B. Instruct the client to use pursed-lip breathing. C. Have the client use the early-morning hours for exercise and activity. D. Provide the client with a low-protein diet.

Answer and Explanation

Choice A:

Restricting the client's fluid intake to less than 2 L/day is not an appropriate intervention for a client with COPD. Adequate hydration is important to help thin mucus secretions and improve respiratory function. Restricting fluids can lead to thicker mucus and exacerbate breathing difficulties.

Choice B:

Instructing the client to use pursed-lip breathing is a beneficial intervention for someone with COPD. Pursed-lip breathing helps improve breathing efficiency by promoting better air exchange and preventing air trapping, which is common in COPD. It helps slow down breathing and increases oxygen saturation.

Choice C:

Having the client use the early-morning hours for exercise and activity might not be the best choice. Morning hours can be when clients with COPD experience more respiratory symptoms. It's advisable to schedule activities during times when the client feels more comfortable and less breathless.

Choice D:

Providing the client with a low-protein diet is not a relevant intervention for COPD management. COPD primarily affects the lungs and respiratory system, and a low-protein diet is not a standard part of its management. Nutritional recommendations for COPD typically focus on maintaining a balanced diet to support overall health.

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Question 2:

A Medical-Surgical nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching?

A. "Cranberry juice can cause bad breath.". B. "You may experience bloating.". C. "Drinking cranberry juice daily can prevent recurrent urinary tract infections.". D. "Cranberry juice can lower cholesterol.".

Answer and Explanation

Choice A:

Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.

Choice B:

Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.

Choice C:

Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.

Choice D:

Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.

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Question 3:

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. Which of the following ethical principles was demonstrated?

A. Veracity. B. Autonomy. C. Nonmaleficence. D. Fidelity.

Answer and Explanation

Choice A:

Veracity refers to truthfulness and honesty in communication between the healthcare provider and the client. It involves providing accurate information and not deceiving the client. Discontinuing the experimental medication due to kidney failure demonstrates a commitment to the truth, but the primary ethical principle demonstrated here is nonmaleficence.

Choice B:

Autonomy refers to respecting the client's right to make their own decisions about their healthcare. In this scenario, the medication was discontinued due to evidence of harm to the client's health. This action prioritizes the client's well-being over their autonomy to continue the treatment.

Choice C:

Nonmaleficence, or the principle of "do no harm," is demonstrated in this scenario. The experimental medication was discontinued because it was causing rapidly advancing kidney failure. The healthcare provider's decision to stop the treatment is an example of prioritizing the client's safety and well-being by preventing further harm.

Choice D:

Fidelity refers to being loyal, keeping promises, and maintaining trust in the nurse-client relationship. While this principle is important, it doesn't directly apply to the situation described, where the focus is on the ethical responsibility to prevent harm.

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Question 4:

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

A. Volunteer to provide an inservice about infection control. B. Speak with the AP when he exits the room about the appropriate protocol. C. Provide the appropriate PPE to the AP. D. Notify the charge nurse about the AP's need for training.

Answer and Explanation

Choice A:

Volunteering to provide an in-service about infection control might be a helpful action, but it does not address the immediate concern of the AP entering the room without appropriate PPE. The priority is to address the situation that has already occurred.

Choice B:

Speaking with the AP when he exits the room about the appropriate protocol is the first action the nurse should take. This approach allows for immediate feedback and correction, helping to prevent potential transmission of infection to the client or others. It's important to address the issue promptly to ensure the safety of everyone involved.

Choice C:

Providing the appropriate PPE to the AP is not the first action the nurse should take. The nurse needs to address the breach in infection control that has already occurred. Providing PPE would be more appropriate as a follow-up step after discussing the situation with the AP.

Choice D:

Notifying the charge nurse about the AP's need for training is a valid action, but it should not be the first step in this scenario. The immediate concern is the potential exposure due to improper PPE use, which should be addressed directly with the AP.

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Question 5:

A nurse is interviewing a female client who is Hispanic. The client's husband answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take?

A. Use an internet webpage translator for the client. B. Arrange to complete the assessment with only the client and a translator present. C. Ask the client's husband to translate questions and answers for the client. D. Ask a male student nurse to translate for the client.

Answer and Explanation

Choice A:

Using an internet webpage translator might seem convenient, but it can lead to inaccuracies in communication due to language nuances and medical terminology. Direct communication with a human translator is more reliable.

Choice B:

Arranging to complete the assessment with only the client and a translator present is the best option. This approach ensures accurate and confidential communication, allowing the nurse to gather essential information directly from the client without potential bias or misinterpretation from family members.

Choice C:

Asking the client's husband to translate questions and answers for the client can lead to inaccurate or biased information. Additionally, it might not provide a safe environment for the client to openly share her concerns.

Choice D:

Asking a male student nurse to translate for the client does not necessarily address the language barrier adequately. The gender of the translator is not the primary concern here. Ensuring effective communication through a professional translator is more important.

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Question 6:

Which nurse kept records on sanitation techniques and the effects on health?

A. Lillian Wald. B. Clara Barton. C. Florence Nightingale. D. Mary Nutting.

Answer and Explanation

Choice A:

Lillian Wald is known for founding the Henry Street Settlement in New York and for her work in public health nursing and social reform, but she is not specifically associated with keeping records on sanitation techniques and their effects on health.

Choice B:

Clara Barton is renowned for establishing the American Red Cross and her humanitarian efforts during the Civil War. While she contributed significantly to healthcare, her focus was not on keeping records on sanitation techniques and their effects.

Choice C:

Florence Nightingale, the founder of modern nursing, is the nurse who kept records on sanitation techniques and their effects on health. She is known for her work during the Crimean War, where she improved sanitation and hygiene practices in healthcare settings, leading to significant improvements in patient outcomes.

Choice D:

Mary Nutting was an influential figure in nursing education, but she is not primarily recognized for keeping records on sanitation techniques and their effects. Her contributions were more related to curriculum development and nursing education.

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Question 7:

A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

A. Airborne. B. Contact. C. Droplet. D. Protective.

Answer and Explanation

Choice A:

Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.

Choice B:

Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.

Choice C:

Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.

Choice D:

Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.

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Amg: This patient should be in protective environment, they had transplant surgery ~ 7mos ago

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Question 8:

A nurse is admitting a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following types of precautions should the nurse plan to initiate?

A. Protective. B. Droplet. C. Airborne. D. Contact.

Answer and Explanation

Choice A:

Protective precautions (also known as reverse isolation) are implemented to protect clients with compromised immune systems from potential pathogens brought in by healthcare providers or visitors. This choice would be appropriate for clients who are highly susceptible to infections, but it's not the primary choice for managing a wound infected with MRSA.

Choice B:

Droplet precautions are utilized for diseases spread by respiratory droplets. MRSA is primarily spread through direct contact with contaminated skin or objects. Therefore, droplet precautions are not the most appropriate choice for this scenario.

Choice C:

Airborne precautions are designed for diseases that spread via small particles suspended in the air, such as tuberculosis. MRSA does not spread through the airborne route, so airborne precautions are not necessary for a wound infection with MRSA.

Choice D:

Contact precautions are the correct choice when dealing with MRSA infections. MRSA is primarily transmitted through direct physical contact or contact with contaminated objects. By implementing contact precautions, the nurse can effectively prevent the spread of the infection to other clients and healthcare workers.

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Question 9:

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A. Provide wound irrigation. B. Avoid accidentally removing the drain. C. Gather supplies. D. Provide analgesic medication as ordered by Provider.

Answer and Explanation

Choice A:

Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.

Choice B:

While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.

Choice C:

Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.

Choice D:

Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.

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Amg: The patient is always priority, pain medication need at least 30 min to work , so medication first ~ 7mos ago

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Question 10:

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

Answer and Explanation

Choice A:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

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