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ATI Foundation of Nursing Exam MSNDE5320
Total Questions : 51
Showing 10 questions, Sign in for moreA nurse is teaching a parent of a-month-old infant about home safety.
Which of the following instructions should the nurse include in the teaching?( select all that apply)
No explanation
What should a nurse include in a nutrition class for pregnant teenagers? Choose all that apply.
Explanation
The correct answer is choicea. Increase daily caloric intake by 300 to 400 calories,b. Consume folic acid supplements daily, andd. Take daily iron and calcium supplements.
Choice A rationale:
Pregnant teenagers need to increase their daily caloric intake by 300 to 400 calories to support the growth and development of the fetus.
Choice B rationale:
Folic acid is crucial for preventing neural tube defects in the developing fetus.Daily supplementation is recommended.
Choice C rationale:
Pregnant teenagers need to increase their protein intake to support fetal growth and maternal health.Maintaining current protein intake is not sufficient.
Choice D rationale:
Iron and calcium are essential for the development of the fetus and the health of the mother.Daily supplementation helps prevent deficiencies.
Choice E rationale:
Limiting weight gain to no more than 15 pounds is not recommended.Healthy weight gain during pregnancy varies but is generally higher than 15 pounds to support fetal development.
The client’s abdomen is soft and nondistended. The ileostomy stoma is red, and the stoma is draining brown liquid stool. The client has expressed discomfort and avoidance, stating they are unwilling to look at or learn about stoma care. The client demonstrates reluctance and avoidance in interacting with the stoma.
The ileostomy pouch was changed this morning. The skin surrounding the stoma is noticeably reddened and has developed small open areas. During the pouch change, a small amount of bleeding was noted from the stoma. The client remains uninterested in learning about stoma care, and the nurse notes an increase in discomfort from the client.
The skin around the stoma appears inflamed with increased erythema and swelling. The stoma is now discolored with a dusky appearance and has been draining a dark, bloody discharge. The client reports increased pain and a feeling of pressure around the stoma. The client continues to refuse education on stoma care, and there is a noted change in the odor of the discharge.
The stoma now has a bluish discoloration with more extensive bleeding observed. The surrounding skin is ulcerated, with large open sores that are oozing. The client is experiencing severe discomfort, with frequent reports of nausea and vomiting. The client’s vital signs show an increased heart rate and a slightly elevated temperature of 37.8°C (100.0°F). The client’s refusal to engage in stoma care education remains unchanged.
- Temperature: 37.8°C (100.0°F)
- Heart Rate: 110 beats per minute
- Blood Pressure: 95/60 mmHg
- Respiratory Rate: 20 breaths per minute
- CBC: Hemoglobin 10.2 g/dL, Hematocrit 30%, White Blood Cells 15,000/µL
- Electrolytes: Sodium 135 mEq/L, Potassium 3.2 mEq/L, Chloride 98 mEq/L
- Stoma culture: Positive for mixed bacteria
A nurse is managing the care of a female client with an ileostomy who has been experiencing complications and has recently undergone a stoma revision. The client’s condition is evolving over several days, and the nurse is reviewing all relevant exhibits to assess the need for further intervention.
Based on the exhibits provided, which findings require immediate intervention by the nurse? Select all that apply.
The client is conscious and alert but appears to be in considerable discomfort. He reports that he tripped over a rug and fell, landing on his right side. He has a visible abrasion on his right elbow and complains of pain in his right hip. His skin is warm to the touch, and he appears to be sweating profusely. He is breathing rapidly and shallowly. He is able to answer questions appropriately but seems anxious.
- Temperature: 37.8°C (100°F)
- Pulse: 110 bpm
- Respirations: 22 breaths/min
- Blood Pressure: 140/90 mmHg
- Oxygen Saturation: 96% on room air
- Hypertension
- Type 2 Diabetes Mellitus
- Osteoarthritis
A nurse is caring for a 68-year-old male client in the accident and emergency department. The client was brought in by his daughter after he fell at home.
The nurse should anticipate which of the following interventions?
The client’s right elbow has a large abrasion with some debris visible in the wound. The skin around the wound is red and slightly swollen. The client winces when the area is touched. He continues to complain of pain in his right hip and is reluctant to move. His breathing remains rapid, and he appears to be slightly pale.
- Temperature: 38.1°C (100.6°F)
- Pulse: 112 bpm
- Respirations: 24 breaths/min
- Blood Pressure: 142/92 mmHg
- Oxygen Saturation: 95% on room air
- Cleanse wound with normal saline.
- Apply topical antibiotic ointment.
- Cover with sterile dressing.
The same nurse is now preparing to clean the abrasion on the client’s right elbow. The provider has prescribed mechanical debridement for the wound.
Which of the following is a form of mechanical debridement that the nurse should expect to use?
The client is alert and oriented to person, place, and time. He voided 350 mL of clear yellow urine into a bedpan. The dressing on his right hip is dry and intact. His abdomen is soft and nondistended, with hypoactive bowel sounds. The client is oriented to person but disoriented to time and place. The client has been incontinent of a moderate amount of urine three times.
- Hemoglobin: 12.5 g/dL
- Hematocrit: 38%
- WBC: 7,000/mm^3
- Platelets: 150,000/mm^3
- Sodium: 140 mEq/L
- Potassium: 4.2 mEq/L
- Calcium: 9.0 mg/dL
A nurse is caring for a 68-year-old male client who was admitted to a rehabilitation unit following a repair of a right hip fracture. The client has limited mobility and requires assistance to turn and transfer out of bed. It’s Day 4, 0700hrs.
The client is at greatest risk for developing
Explanation
The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.
The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.
A nurse is about to replace a nearly depleted container of total parenteral nutrition (TPN) for a patient, but discovers a delay in the delivery of the new TPN solution from the pharmacy.
Which solution should the nurse administer until the next TPN solution is available?
A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound and is about to check the patient’s pulse.
What precautions should the nurse take?
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