ATI COMPREHENSIVE ATI A
• A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the n
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ATI COMPREHENSIVE ATI A
• A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take?
ANS: Escort the client to a quiet area on the nursing unit.
• A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands.
• A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination?
ANS: Use intermittent urinary catheterization for the client at regular intervals.
• A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch.
• A nurse is assisting with an education program about car restraint safety for a group of parents. Which statement by the parent indicates an understanding of the instructions?
ANS: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”
• When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash.
• A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which instructions should the nurse include in the teaching?
ANS: Drink high-protein and high-calorie nutritional supplements.
• The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism and wasting of the client’s muscle mass.
• When removing PPE after direct care for a client who requires airborne & contact precautions, which PPE is removed first?
ANS: Gloves
• The greatest risk is contamination from pathogens that might be present on the PPE; therefore, the priority action for the AP is to remove the gloves, which are considered the most contaminated.
• A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP?
ANS: Generalized Petechiae
• Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal
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