Review ATI PN Fundamentals 2023 Exam 4

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ATI PN Fundamentals 2023 Exam 4

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Total Questions : 70

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Question 1:

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain.
Which of the following statements by the client indicates an understanding of this technique?

A. "I think about my grandfather's farm to reduce pain.”. B. "I listen to my favorite music to take my mind off the pain.”. C. "I use focused breathing to control my pain.”. D. "I learn to notice the sensation of muscle tension.”.

Answer and Explanation

Choice A:

Guided imagery involves the use of mental visualization to relieve stress and manage pain. By thinking about a peaceful setting, such as the client’s grandfather's farm, they can divert attention from the pain and enter a state of relaxation. This technique helps reduce pain perception by engaging the mind in positive, soothing imagery, which can lead to decreased stress and muscle tension.

Choice B:

Listening to music is a distraction technique rather than guided imagery. While it can help take the mind off pain, it does not involve the mental visualization process that is central to guided imagery. Music can help by shifting attention away from pain and providing a calming effect through auditory stimulation.

Choice C:

Focused breathing is a relaxation technique that can help manage pain through controlled breathing patterns. It helps reduce anxiety and physical tension by focusing on slow, deep breaths. However, it does not involve the imaginative visualization that characterizes guided imagery.

Choice D:

Noticing the sensation of muscle tension is part of body awareness techniques, which involve paying attention to and understanding bodily sensations. While this can help in managing pain by addressing muscle tension, it is different from the mental visualization process of guided imagery.

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Question 2:

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality.
In which of the following situations can the nurse disclose health information without the client's written consent?

A. To an employer for a pre-employment screening. B. To a family member when the client is not available. C. To a medical interpreter service on behalf of a client. D. To an insurance agency in regard to a life insurance policy.

Answer and Explanation

Choice A:

Health information should not be disclosed to an employer for pre-employment screening without the client's consent, as it violates privacy regulations and the client's right to confidentiality. Such disclosures could lead to discrimination or bias in employment decisions.

Choice B:

Disclosing health information to a family member without the client's consent is a breach of confidentiality. The client must provide explicit permission, unless the situation involves an immediate risk to the client's or others' safety, which is not indicated here.

Choice C:

Sharing health information with a medical interpreter service on behalf of a client is permissible, as it facilitates communication between the client and healthcare providers. This action supports the client's care and ensures accurate understanding of medical information, making it an exception to the confidentiality rule.

Choice D:

Disclosing health information to an insurance agency regarding a life insurance policy requires the client's consent. It involves sharing sensitive information that could affect policy terms and premiums. Without consent, this disclosure would breach confidentiality laws.

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Question 3:

A home health nurse is visiting a client who has advanced Alzheimer's disease.
The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

A. "We can discuss this when you're not feeling overwhelmed.”. B. "Have you tried taking your partner with you when you go out?" C. "Tell me more about your expectations.”. D. "I understand how you feel. I've had a relative go through the same thing.”

Answer and Explanation

Choice A:

Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.

Choice B:

Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.

Choice C:

Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.

Choice D:

While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.

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Question 4:

A nurse is recording the intake and output (I&O) for a client.

The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits.

Which volume should the nurse record on the I&O?

Answer and Explanation

Correct Answer: "660" mL

Explanation

Step 1: Convert all liquid intake to mL: 8 oz of milk = 8 oz × 30 mL/oz = 240 mL 10 oz of water = 10 oz × 30 mL/oz = 300 mL 4 oz of gelatin = 4 oz × 30 mL/oz = 120 mL

Step 2: Sum the liquid intake: Total intake = 240 mL + 300 mL + 120 mL = 660 mL

The nurse should record 660 mL on the I&O.

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Question 5:

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band.
Which of the following actions should the nurse take to verify the client's identity?

A. Review the client's photograph in the medical record. B. Request an assistive personnel to identify the client. C. Ask the client to state their room number. D. Have the client state their phone number.

Answer and Explanation

Choice A:

Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.

Choice B:

Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.

Choice C:

Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.

Choice D:

Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.

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Question 6:

A nurse is participating in a group discussion about complicated grief associated with loss.
Which of the following should the nurse identify as an example of exaggerated grief?

A. A client whose grief response is repressed. B. A client whose grief response begins following a terminal diagnosis. C. A client whose grief response leads to self-destructive behaviors. D. A client whose grief response is triggered by a secondary loss.

Answer and Explanation

Choice A:

A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.

Choice B:

Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.

Choice C:

Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.

Choice D:

A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.

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Question 7:

A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.
Which of the following actions by the AP requires intervention by the nurse?

A. Using a quick-release tie to secure the restraint. B. Tying the restraint to the bed frame. C. Placing the restraint across the client's chest. D. Applying the restraint over the client's gown.

Answer and Explanation

Choice A:

Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.

Choice B:

Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.

Choice C:

Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.

Choice D:

Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.

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Question 8:

A charge nurse is observing a newly licensed nurse who is caring for a group of clients.
Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

A. "I will use disinfectant to clean the blood pressure cuff after use on a client.”. B. "I will double-bag a client's linens each day.”. C. "I will wear sterile gloves when bathing a client who is incontinent.”. D. "I will rinse the contaminants from a bedpan with hot water.”. .

Answer and Explanation

Choice A:

Using disinfectant to clean the blood pressure cuff after use is an appropriate infection control measure. It reduces the risk of cross-contamination between clients by ensuring medical equipment is sanitized.

Choice B:

Double-bagging a client's linens each day is not necessary unless the linens are heavily soiled or contaminated with pathogens. Routine double-bagging is not an effective infection control practice and is resource-intensive.

Choice C:

Wearing sterile gloves when bathing a client who is incontinent is unnecessary. Non-sterile gloves are sufficient for this task, and sterile gloves should be reserved for surgical or invasive procedures to maintain sterility.

Choice D:

Rinsing contaminants from a bedpan with hot water can create aerosols that spread pathogens. Proper protocol involves cleaning and disinfecting the bedpan with appropriate solutions to ensure infection control. .

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Question 9:

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy.
In which order should the nurse complete the following steps?

A. Unlock and remove the inner cannula. B. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. C. Scrub the inside and outside of the inner cannula with a small brush. D. Wipe the inside of the inner cannula with a folded pipe cleaner. E. Cleanse the stoma site with 0.9% sodium chloride solution.

Answer and Explanation

Explanation

Choice A rationale

Unlocking and removing the inner cannula is the first step. It allows access to the inner cannula for cleaning and ensures that the tracheostomy tube remains patent.

Choice B rationale

Pouring 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin provides the necessary solution for cleansing the inner cannula and stoma site, helping to maintain sterility and prevent infection.

Choice C rationale

Scrubbing the inside and outside of the inner cannula with a small brush ensures that any mucus or debris is removed, reducing the risk of infection and maintaining clear airways.

Choice D rationale

Wiping the inside of the inner cannula with a folded pipe cleaner helps to remove any remaining debris or solution, ensuring that the inner cannula is thoroughly cleaned.

Choice E rationale

Cleansing the stoma site with 0.9% sodium chloride solution helps to remove any mucus or debris from the site, maintaining hygiene and reducing the risk of infection.

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Question 10:

A nurse is reinforcing teaching with a client about how to collect a stool specimen.
Which of the following instructions should the nurse include?

A. Avoid placing toilet tissue in the bedpan after defecation. B. Urinate after the specimen collection. C. Place 1.3 cm (0.5 in) of formed stool into a culture tube. D. Keep the specimen in a warm area.

Answer and Explanation

Choice A:

Avoid placing toilet tissue in the bedpan after defecation to prevent contamination of the stool specimen. Toilet tissue can introduce foreign substances that may interfere with lab results.

Choice B:

Urinate after the specimen collection is incorrect because urine can contaminate the stool sample. The client should urinate before collecting the stool specimen to avoid mixing the two.

Choice C:

Placing 1.3 cm (0.5 in) of formed stool into a culture tube is insufficient for a proper stool sample. Typically, a larger sample is needed to ensure enough material is available for testing.

Choice D:

Keeping the specimen in a warm area is incorrect because stool samples should be kept in a cool environment to preserve the integrity of the specimen until it can be analyzed.

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Total Questions : 70

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ATI PN Fundamentals 2023 Exam 4

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