Review Ati foundation of nursing msnde5320

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Ati foundation of nursing msnde5320

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Total Questions : 44

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Question 1:

Which of the following is an appropriate evaluation method to assess the effectiveness of home care teaching after a client has surgery?

A. Sending a follow-up survey via email to assess the client's satisfaction with the teaching provided B. Asking the client if they have any questions or concerns about their home care instructions C. Asking the client to demonstrate the proper technique for dressing their surgical incision D. Reviewing the client's vital signs to ensure they are within normal limits.

Answer and Explanation

Choice A:

This is a good method to gather feedback but does not directly assess the client's ability to perform the taught skills.

Choice B:

This is important to identify knowledge gaps but does not assess the client's ability to perform the skills.

Choice C:

This is the most direct way to assess the client's ability to perform the taught skill and ensures that the client has retained the information.

Choice D:

While important, vital signs do not directly assess the effectiveness of home care teaching.

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Question 2:

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?

A. pH 7.35, PaCO2 40 mm Hg, HCO3-25 mEq/L B. pH 7.32, PaCO2 47 mm Hg. HCO3-23 mEq/L C. pH 7.3, PaCO2 36 mm Hg. HCO3- 19 mEq/L D. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L

Answer and Explanation

Choice A:

pH 7.35, PaCO2 40 mm Hg, HCO3-25 mEq/L: This is within normal ranges and does not indicate acidosis.

Choice B:

pH 7.32, PaCO2 47 mm Hg. HCO3-23 mEq/L: This indicates respiratory acidosis, not metabolic.

Choice C:

pH 7.3, PaCO2 36 mm Hg. HCO3- 19 mEq/L: This indicates metabolic acidosis. The pH is low (acidic), and the HCO3- (bicarbonate) is decreased. The PaCO2 is within normal limits, indicating the respiratory system is compensating for the metabolic acidosis.

Choice D:

pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L: This indicates alkalosis, not acidosis.

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Question 3:

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

A. Spoon nails B. Peripheral edema C. Pleural friction rub D. Barrel chest

Answer and Explanation

Choice A:

This is associated with iron deficiency anemia, not COPD.

Choice B:

While peripheral edema can occur in advanced COPD due to right-sided heart failure (cor pulmonale), it's not a typical early finding.

Choice C:

This is associated with inflammation of the pleural layers, typically due to pneumonia or pleurisy, not COPD.

Choice D:

Barrel chest is a classic sign of COPD, resulting from air trapping in the lungs, causing the chest to become hyperinflated

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Question 4:

A post-operative patient is at risk for developing a wound infection. Which of the following nursing assessments is the highest priority to prevent this complication?

A. Monitoring the patient's vital signs B. Assessing the patient's pain level C. Inspecting the surgical incision site for redness, swelling D. Assessing the patient's fluid intake and output

Answer and Explanation

Choice A:

While important for overall patient assessment, it's not the most direct way to monitor for a wound infection.

Choice B:

Pain can indicate a wound infection, but it's not as specific as directly inspecting the wound.

Choice C:

This is the most direct way to assess for early signs of a wound infection. Redness, swelling, warmth, and drainage are classic signs of infection.

Choice D:

Important for overall patient care, but not specifically related to wound infection prevention.

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Question 5:

Which of the following is a risk factor for developing thromboembolism in the post surgical setting?

A. Regular ambulation B. Obesity C. Young age D. Adequate hydration

Answer and Explanation

Choice A:

This actually helps prevent thromboembolism by promoting blood flow.

Choice B:

Increased body weight can contribute to blood clotting, increasing the risk of thromboembolism.

Choice C:

While not impossible, younger individuals are generally at lower risk for thromboembolism compared to older adults.

Choice D:

Proper hydration helps maintain blood flow and can reduce the risk of blood clots.

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Question 6:

A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood?

A. Lymphocytes B. Neutrophils C. Platelets D. Hemoglobin

Answer and Explanation

Choice A:

Lymphocytes are a type of white blood cell that plays a crucial role in the immune system, specifically in the response to infections and in immune regulation. They do not have a role in the transport of oxygen in the blood.

Choice B:

Neutrophils are another type of white blood cell that is essential for fighting bacterial infections. They are part of the body's immune response but do not transport oxygen.

Choice C:

Platelets are small cell fragments that are crucial for blood clotting and wound repair. They do not have a role in oxygen transport.

Choice D:

Hemoglobin is the primary molecule responsible for transporting oxygen in the blood. It is a protein found in red blood cells (erythrocytes) that binds to oxygen in the lungs and releases it in tissues throughout the body. Hemoglobin carries the majority of oxygen in the bloodstream and is essential for effective oxygen transport and delivery.

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Question 7:

A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out?
(Select All that Apply.)

A. Ask the client to read their identification bracelet. B. Ask the client to point to the surgical site. C. Use two acceptable client identifiers. D. Verify that the surgical site has been marked. E. Ask the client to state the surgery being performed.

Answer and Explanation

Choice A:

Asking the client to read their identification bracelet can be additional verification steps, but it is not standard practice for all institutions

Choice B:

To point to the surgical site can be additional verification steps, but it is not standard practice for all institutions.

Choice C:

Using two acceptable client identifiers, such as the client's name and date of birth, to confirm the patient's identity.

Choice D:

It is important to verify that the surgical site has been marked, which is a critical step in preventing wrong-site surgery.

Choice E:

Asking the client to state the surgery being performed is a good practice as it involves the patient in their care and serves as a final verification of the correct procedure.

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Question 8:

A nurse teaches a post-operative patient about preventing atelectasis. Which statement by the patient indicates an understanding?

A. “Hyperventilation will open up my alveoli, preventing atelectasis." B. “It is important for me to do breathing exercises every hour to prevent atelectasis." C. "Atelectasis affects only those with chronic conditions such as emphysema. I do not have emphysema therefore I will not get this condition." D. “If develop atelectasis, I will need a chest tube to drain excess fluid."

Answer and Explanation

Choice A:

Hyperventilation can lead to dizziness and lightheadedness, and it's not a recommended method for preventing atelectasis.

Choice B:

This statement indicates understanding of the importance of deep breathing exercises in preventing atelectasis.

Choice C:

This statement shows a misunderstanding of atelectasis. Anyone can develop atelectasis, especially after surgery.

Choice D:

This statement is incorrect, but it focuses on treatment rather than prevention.

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Question 9:

Which of the following is a postoperative risk factor specifically associated with older adults?

A. Decreased renal function B. Seasonal allergies C. Family history of cancer D. Hypertension

Answer and Explanation

Choice A:

Decreased renal function is a common age-related change that can significantly increase postoperative complications, such as fluid and electrolyte imbalances, and medication toxicity.

Choice B:

Seasonal allergies are not specifically related to postoperative risks and can affect people of all ages.

Choice C:

Family history of cancer is a general health risk factor, not specifically postoperative.

Choice D:

Hypertension is a common chronic condition that can affect people of all ages and while it can increase postoperative risks, it's not specific to older adults.

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Question 10:

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

A. Turn the patient's head to suction more effectively. B. Administer an antidysrhythmic medication. C. Stop suctioning, allow patient to rest and reassess the need to continue suctioning. D. Obtain a cardiology consult.

Answer and Explanation

Choice A:

Changing the patient's head position during suctioning can increase discomfort and hypoxia.

Choice B:

This is premature. The tachycardia may be a temporary response to the suctioning procedure.

Choice C:

The increased heart rate is likely a response to the stimulation of suctioning. Stopping the procedure allows the patient to recover and reassessment can determine if further suctioning is necessary.

Choice D:

This is excessive and not necessary at this time.

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Total Questions : 44

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Ati foundation of nursing msnde5320

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