ATI-F ATI Fundamentals - Set 5 - Part 3

Correct Answer: Raise the head of the bed

Raising the head of the bed to a sitting position eases breathing by allowing fuller lung expansion. Using the airway-breathing approach, the nurse positions the client upright first to relieve the difficulty. Option a is incorrect because raising the room temperature does nothing to improve the client's breathing. The first action is to position the client upright, not to change the temperature of the room. Option c is incorrect because documenting the complaint delays the help the struggling client needs right now. The nurse first sits the client upright to ease breathing, then documents the event afterward. Option d is incorrect because leaving to find the provider abandons the client during respiratory distress. The nurse stays and positions the client upright first, calling for help without leaving the bedside.

Correct Answer: An x-ray of the tube

An x-ray is the most reliable method to confirm a newly placed nasogastric tube is in the stomach. The nurse verifies placement by x-ray before using the tube for feeding or medication. Option b is incorrect because injecting air and listening over the abdomen is no longer an acceptable way to confirm placement. The sound can be misleading, so an x-ray is used instead for a new tube. Option c is incorrect because asking the client how the tube feels does not confirm where the tip is located. The client's sensation is unreliable, so an x-ray is needed to verify the correct placement. Option d is incorrect because watching for a cough does not reliably confirm or rule out correct placement. An x-ray, not a behavioral sign, is the dependable method for a newly inserted tube.

Correct Answer: Stop the feeding

If aspiration is suspected during a tube feeding, the first action is to stop the feeding so no more formula enters the airway. The nurse then turns the client and provides further care. Option a is incorrect because increasing the rate of the feeding sends more formula in and worsens the aspiration. The nurse stops the feeding immediately rather than speeding it up when aspiration is suspected. Option b is incorrect because laying the client flat lets formula flow toward the airway and increases aspiration. The client is turned to the side, and the feeding is stopped first, not laid flat. Option c is incorrect because giving water to drink during suspected aspiration adds more fluid to the airway and risks choking. The first step is to stop the feeding, not to offer anything by mouth.

Correct Answer: Report the finding to the provider

Dark, coffee-ground drainage can indicate bleeding in the stomach. The nurse reports this finding to the provider promptly so the cause can be investigated and treated for the client without delay. Option a is incorrect because flushing the tube with air does not address possible bleeding and could worsen the situation. The nurse reports the coffee-ground drainage rather than flushing the tube with air. Option b is incorrect because continuing care without concern overlooks a sign of possible gastric bleeding. Coffee-ground drainage needs to be reported, not ignored, so the underlying cause can be found and treated. Option d is incorrect because removing the tube right away is outside the nurse's independent action and may not be needed. The nurse first reports the finding to the provider rather than pulling the tube.

Correct Answer: Reposition the client at least every two hours

Repositioning a bedbound client at least every two hours relieves pressure over bony areas and protects the skin. Regular turning keeps blood flowing and is a key step in preventing pressure injuries. Option b is incorrect because massaging reddened bony areas can damage fragile tissue and worsen the injury. Bony prominences are not massaged; instead, pressure is relieved by repositioning the client on a regular schedule. Option c is incorrect because applying powder to skin folds can cake, abrade the skin, and pose an inhalation risk. Powder is avoided, and the skin is kept clean and dry to prevent breakdown. Option d is incorrect because keeping the head of the bed raised high increases shearing and pressure on the lower body. The head of the bed is kept low when possible to reduce the pressure injury risk.

Correct Answer: Cover it with a saline-soaked sterile dressing

Protruding intestine through an open incision is evisceration, an emergency. The nurse covers the area with a sterile saline-soaked dressing to keep the tissue moist, calls for help, and prepares the client for surgery. Option a is incorrect because pushing the intestine back into the abdomen can damage the tissue and introduce infection. The protruding organ is covered and kept moist, never pushed back inside by the nurse. Option c is incorrect because leaving the wound open to the air lets the exposed tissue dry out and become damaged. A sterile saline-soaked dressing is applied to keep the organ moist until surgery. Option d is incorrect because having the client sit fully upright increases pressure on the wound and worsens the protrusion. The client is positioned supine with the knees bent to reduce strain on the incision.

Correct Answer: Contact precautions with gown and gloves

A multidrug-resistant wound infection spreads by contact, so the nurse uses contact precautions with a gown and gloves. These barriers stop the organism from spreading by touch to other clients. Option a is incorrect because airborne precautions and a respirator are for organisms that travel through the air, not by contact. A resistant wound infection spreads by touch, so contact precautions are the correct choice. Option b is incorrect because droplet precautions and a mask address respiratory droplets, not contact spread. The wound organism spreads through contact, which calls for a gown and gloves rather than droplet protection. Option c is incorrect because using no special precautions would let the resistant organism spread to others. Contact precautions are required for a multidrug-resistant wound infection, so omitting them is unsafe.

Correct Answer: Dry mucous membranes and poor skin turgor

Fluid volume deficit reduces body fluid, producing dry mucous membranes, poor skin turgor, and increased thirst. The nurse expects these signs of dehydration when assessing a client with a fluid deficit. Option a is incorrect because a bounding pulse and high blood pressure suggest fluid excess, not deficit. A client with a fluid deficit more often shows a weak, fast pulse and low blood pressure instead. Option b is incorrect because crackles in the lungs and edema are signs of fluid overload, the opposite of a deficit. These findings point to too much fluid rather than the loss that defines a deficit. Option d is incorrect because distended neck veins and weight gain reflect fluid excess rather than deficit. A fluid deficit usually causes weight loss and flat neck veins, not these signs of overload.

Correct Answer: Place the client on airborne precautions

Tuberculosis spreads through the air, so the nurse places a client with suspected tuberculosis on airborne precautions first. This includes a private negative-pressure room and a fitted respirator to protect others right away. Option b is incorrect because contact precautions alone do not protect against an organism that travels through the air. Suspected tuberculosis requires airborne precautions, which contact precautions by themselves do not provide. Option c is incorrect because placing the client in a shared room exposes others to a possible airborne infection. A private negative-pressure room with airborne precautions is needed, not a shared room. Option d is incorrect because waiting for the diagnosis before acting allows the organism to spread in the meantime. The nurse implements airborne precautions immediately when tuberculosis is suspected, not after confirmation.

Correct Answer: Bananas

Bananas are rich in potassium, so the nurse encourages them for a client whose medication can lower potassium levels. Including high-potassium foods helps keep the client's potassium within a healthy range. Option a is incorrect because white rice is low in potassium and does little to replace what the medication removes. The nurse recommends potassium-rich foods like bananas rather than low-potassium white rice. Option b is incorrect because plain pasta contains little potassium and would not help maintain the client's level. Foods high in potassium, such as bananas, are encouraged instead of low-potassium pasta. Option c is incorrect because egg whites are not a significant source of potassium for this client. The nurse encourages potassium-rich choices like bananas rather than egg whites to support the potassium level.