ATI-F ATI Fundamentals - Set 5 - Part 2

Correct Answer: Left side-lying with the right leg flexed

The client lies on the left side with the right leg flexed for an enema. This position follows the natural curve of the colon and helps the solution flow in and be retained for cleansing. Option a is incorrect because lying flat on the back with the legs straight does not align with the colon and makes the enema harder to give. The left side-lying position is used instead for safe administration. Option b is incorrect because sitting upright on a chair forces the solution against gravity and out before it can work. The client lies on the left side rather than sitting during the enema. Option d is incorrect because standing and leaning forward is unsafe and does not allow the solution to flow into the colon properly. The correct position is left side-lying with the right leg flexed.

Correct Answer: Below the level of the bladder

The drainage bag is kept below the level of the bladder so urine flows downward and away from the client. This prevents urine from flowing back into the bladder and causing an infection. Option b is incorrect because keeping the bag above the bladder lets urine flow backward toward the client. This backflow raises the risk of infection, so the bag is kept below bladder level instead. Option c is incorrect because placing the bag at chest height is well above the bladder and promotes backflow of urine. The bag belongs below the bladder, not raised up near the chest. Option d is incorrect because hooking the bag over the side rail can raise it above bladder level and is not secure. The bag is kept below the bladder and attached to the bed frame instead.

Correct Answer: Face the client and speak clearly

Facing the client and speaking clearly lets the client see the lips and facial cues, which aids understanding. The nurse also tries lowering the pitch of the voice before raising the volume. Option a is incorrect because shouting loudly into the ear distorts the sound and can be uncomfortable without improving understanding. Facing the client and speaking clearly works far better than shouting at them. Option b is incorrect because covering the mouth hides the lip movements and expressions that help the client follow speech. The nurse keeps the face visible while speaking to support the client's understanding. Option c is incorrect because speaking quickly makes words harder to follow for a client with hearing loss. A clear, unhurried pace while facing the client supports much better understanding for the client.

Correct Answer: Guided imagery

Guided imagery is a complementary therapy a nurse can provide without special certification once the principles are understood. The nurse can use it to help the client relax and manage discomfort. Option a is incorrect because acupuncture requires specialized training and licensing to perform safely. It is not a therapy a nurse can provide without that specialized certification, unlike the guided imagery option here. Option b is incorrect because a chiropractic adjustment is performed by a licensed chiropractor with specialized training. A nurse cannot provide this therapy, so it does not fit what the nurse can offer. Option d is incorrect because biofeedback therapy requires special training and equipment to deliver properly. It is outside what a nurse can provide without certification, making it the wrong choice here.

Correct Answer: Check two client identifiers

Verifying two client identifiers, such as the name and identification number, confirms the right client before giving medication. Using two identifiers prevents errors that could occur from relying on location or a single check. Option a is incorrect because using the room number alone is unreliable because clients can move or be reassigned. A single, location-based check does not safely confirm identity the way two identifiers do. Option c is incorrect because simply asking if the client is correct does not meet the standard for two identifiers. A confused client may answer inaccurately, so additional reliable verification is still required. Option d is incorrect because relying on the bed location alone risks giving medication to the wrong person. Beds and rooms change, so two identifiers, not location, are used to confirm the client's identity.

Correct Answer: Immediately after administration

The nurse documents a medication immediately after giving it, including the client's response. Charting after administration, never before, keeps the record accurate and prevents recording a dose that was not actually given. Option a is incorrect because documenting before preparing the medication records a dose that has not been given yet. If something interrupts the process, the record would be false, so charting comes after administration. Option b is incorrect because charting before entering the room marks the medication as given before it actually is. This risks an inaccurate record, so the nurse documents only after the client receives the dose. Option c is incorrect because waiting until the end of the shift to document risks forgetting details or doses. The nurse records each medication right after giving it to keep the record timely and accurate.

Correct Answer: Give the tablet whole

An enteric-coated tablet is given whole so the special coating stays intact. Crushing or chewing it would destroy the coating that protects the stomach and controls where the medication is released. Option a is incorrect because crushing an enteric-coated tablet breaks the protective coating and can irritate the stomach or release the drug too early. The tablet must be swallowed whole instead of crushed. Option b is incorrect because letting the client chew the tablet destroys the coating designed to stay intact until later. Chewing defeats the purpose of the enteric coating, so the tablet is swallowed whole. Option d is incorrect because dissolving the tablet in juice breaks down the coating just as crushing would. The enteric coating must remain intact, so the tablet is given whole rather than dissolved.

Correct Answer: Into the lower conjunctival sac

Eye drops are placed into the lower conjunctival sac, formed by gently pulling down the lower lid. This avoids the sensitive cornea and lets the medication spread safely across the eye. Option b is incorrect because placing drops directly onto the cornea is uncomfortable and can trigger blinking that expels the medication. The drops go into the lower conjunctival sac instead of onto the cornea. Option c is incorrect because dropping medication at the inner corner lets it drain into the tear duct rather than coat the eye. The lower conjunctival sac is the correct location for instilling eye drops. Option d is incorrect because placing drops on the upper eyelid surface does not deliver the medication into the eye. The drops belong in the lower conjunctival sac, not on the outside of the lid.

Correct Answer: Rinse the mouth after each use

Rinsing the mouth after each use of a corticosteroid inhaler removes residual medication that can lead to a fungal infection. The nurse teaches this simple step to protect the client's mouth and throat. Option a is incorrect because avoiding water all day does not prevent a fungal infection and could cause dehydration. Rinsing the mouth after the inhaler, not limiting fluids, is the protective measure here. Option b is incorrect because using the inhaler only once a week ignores the prescribed schedule and would undertreat the condition. The client follows the prescription and rinses the mouth to prevent infection. Option c is incorrect because holding the breath helps the medication reach the lungs but does not prevent a mouth infection. Rinsing afterward is the step that removes residue and protects against fungal growth.

Correct Answer: Check the client for allergies

Checking the client for allergies is a priority before giving any new medication, because an allergic reaction can be serious. The nurse confirms allergy status by asking and reviewing the record first. Option a is incorrect because documenting before the dose is given records care that has not happened and is unsafe. Charting comes after administration, and checking allergies must occur before giving the medication. Option b is incorrect because crushing the tablet may be unnecessary or even unsafe for certain forms, and it does not address allergy risk. Confirming allergies comes first, before any medication is prepared. Option d is incorrect because leaving medication at the bedside is never appropriate and skips the needed safety checks. The nurse confirms allergies and watches the client take the dose rather than leaving it.

Correct Answer: Respect the refusal and notify the provider

A competent client has the right to refuse medication. The nurse respects the refusal, explains the possible consequences, notifies the provider, and documents the event rather than forcing the medication. Option b is incorrect because hiding medication in food is deceptive and violates the client's right to refuse. A competent client must be informed, so concealing the dose is unethical and inappropriate. Option c is incorrect because insisting the client take the medication ignores their legal right to refuse care. The nurse informs the client of the risks but does not force a competent adult to comply. Option d is incorrect because documenting that the client took it would be false, since the client refused. Accurate charting reflects the refusal, the provider notification, and the teaching the nurse provided.

Correct Answer: Prepare epinephrine and call for help

These findings signal anaphylaxis, a life-threatening allergic reaction. The priority is to prepare epinephrine and summon emergency help, because rapid treatment is needed to open the airway and support circulation. Option a is incorrect because applying a warm compress to hives does nothing for a swelling airway and wastes critical time. Anaphylaxis requires epinephrine and emergency help, not a comfort measure for the skin. Option c is incorrect because offering water to a client with a swelling throat risks choking and ignores the emergency. The priority is epinephrine and calling for help, not giving the client something to drink. Option d is incorrect because documenting and waiting delays the urgent treatment a client in anaphylaxis needs. The nurse acts immediately with epinephrine and help rather than pausing to chart the reaction.

Correct Answer: Sip water often for dry mouth

Anticholinergic effects often include a dry mouth, so the nurse teaches the client to sip water frequently for relief. The nurse also addresses constipation, sensitivity to light, and other anticholinergic effects. Option b is incorrect because avoiding all fiber worsens the constipation that anticholinergic effects can cause. The nurse encourages fiber and fluids, not their removal, to keep the client's bowels moving regularly. Option c is incorrect because spending extra time in bright sun aggravates the light sensitivity these medications can cause. The client is advised to wear sunglasses, not to seek out bright light. Option d is incorrect because limiting fluids does not relieve anticholinergic effects and can worsen constipation and dry mouth. The client is encouraged to drink water rather than restrict fluids to avoid urinating.

Correct Answer: Avoid grapefruit juice with this medication

Grapefruit juice can increase the absorption of certain medications and raise the risk of toxicity. The nurse teaches the client to avoid grapefruit juice while taking the medication to keep blood levels safe. Option a is incorrect because drinking extra grapefruit juice increases medication absorption and the risk of toxic blood levels. The client is told to avoid it, not to consume more of the juice. Option b is incorrect because taking the medication with grapefruit juice is exactly what should be avoided. The juice raises absorption and can push the medication to a toxic level in the blood. Option d is incorrect because replacing water with grapefruit juice increases exposure to the interaction. The client uses water and avoids grapefruit juice to prevent the medication from reaching a harmful level.

Correct Answer: Stop the infusion

A cool, pale, swollen site indicates infiltration, where fluid leaks into the tissue. The first action is to stop the infusion and remove the catheter so no more fluid enters the tissue. Option a is incorrect because increasing the infusion rate pushes more fluid into the tissue and worsens the infiltration. The nurse stops the infusion rather than speeding it up when these signs appear. Option b is incorrect because applying pressure and continuing the infusion ignores the problem and lets more fluid leak. The infusion must be stopped first, not maintained, when infiltration is suspected. Option c is incorrect because massaging the swollen area can worsen tissue damage and is not the first step. The nurse stops the infusion and removes the catheter before considering any other measure.

Correct Answer: Dilute it and infuse it slowly

Intravenous potassium is always diluted and infused slowly with a pump, never given as a bolus. A rapid bolus can cause a fatal cardiac arrest, so slow, controlled infusion is essential for safety. Option a is incorrect because giving potassium as a rapid bolus can stop the heart and is never done. The medication must be diluted and infused slowly to be safe for the client. Option c is incorrect because pushing potassium quickly to save time risks a deadly cardiac event. Safety requires diluting the medication and infusing it slowly, not rushing the dose into the client's vein. Option d is incorrect because injecting potassium directly without dilution exposes the heart to a dangerous concentration. The medication is always diluted and infused slowly with a pump to protect the client from cardiac arrest.

Correct Answer: Lung crackles and distended neck veins

Fluid overload from too much intravenous fluid causes the lungs to fill with fluid and the neck veins to distend. Crackles and distended neck veins are key signs the nurse reports promptly. Option a is incorrect because dry mucous membranes and thirst are signs of a fluid deficit, not overload. They point to too little fluid rather than the fluid excess that overload describes in a client. Option b is incorrect because sunken eyes and poor skin turgor reflect dehydration, the opposite of fluid overload. These findings suggest the client needs more fluid, not that they have too much. Option d is incorrect because low blood pressure and a weak pulse are findings of a fluid deficit or shock. Fluid overload more often raises the blood pressure and produces a bounding pulse instead.

Correct Answer: Wipe away the first drop of blood

The first drop of blood can be mixed with tissue fluid, so the client wipes it away and uses the next drop for the most accurate reading. This improves the reliability of the glucose result. Option b is incorrect because cleaning the finger with alcohol can interfere with the result and dry the skin. Warm water and soap are used instead, since alcohol residue may affect the glucose reading. Option c is incorrect because squeezing the finger forcefully adds tissue fluid to the blood and causes pain and bruising. Gentle technique, not forceful squeezing, gives a more accurate glucose sample. Option d is incorrect because smearing the blood across the strip produces an inaccurate reading. The client places a drop onto the strip without smearing it to get a correct glucose result.

Correct Answer: Keep oxygen away from open flames

Oxygen makes fire start and spread quickly, so the nurse teaches the client to keep it away from open flames and all smoking. Posting no-smoking signs and avoiding sparks protect the client from a fire. Option a is incorrect because wool blankets can create static sparks near oxygen and raise the fire risk. Cotton bedding is used instead, so wool near oxygen is unsafe rather than helpful. Option b is incorrect because storing oxygen beside the stove places it next to an open flame and heat. Oxygen must be kept away from flames and heat sources, not set near the stove. Option c is incorrect because allowing smoking in the same room as oxygen creates a serious fire hazard. No smoking is permitted near oxygen, so this instruction would put the client in danger.

Correct Answer: Restlessness and confusion

Early hypoxia produces restlessness, anxiety, and confusion as the brain senses falling oxygen. The nurse recognizes these early signs and acts before later findings like cyanosis and a slow pulse appear. Option a is incorrect because bluish color of the lips is a late sign of hypoxia, not an early one. By the time cyanosis appears, oxygen has already dropped significantly, so it is not the early indicator. Option b is incorrect because a very slow heart rate is a late hypoxia finding. Early on the heart rate rises, so a slow rate signals that hypoxia has progressed rather than just begun. Option d is incorrect because low blood pressure appears late in hypoxia, after compensation fails. Early hypoxia tends to raise the blood pressure, so a low pressure is not the early sign the nurse watches for.