PN2 NUR 2571 Basic Care and Comfort ATI_2020 – Rasmussen College | PN2 NUR2571 Basic Care and Comfort ATI_2020

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PN2 NUR 2571 Basic Care and Comfort ATI – Rasmussen College 92% Accurate. • A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which statement to t... he nurse indicates a need for further teaching? • a. I only need to catheterize myself twice a day
 • b. I carry a water bottle with me because I drink a lot of water
 • c. I use a suppository every night to have a bowel movement
 • d. I do wheelchair exercises while watching TV • A nurse is providing hygiene care for a client who is immobile. Which actions should the nurse take? (select all that apply)

 • a. Check for personal items when changing linens
 • b. Place clean gown on strongest arm first
 • c. Keep bath water temp between 110-115 degF
 • d. Shave hair in direction of growth
 • e. Wash extremities from proximal to distal • A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

 • a. Trochanter roll
 • b. Sheepskin heel pad
 • c. Abduction pillow
 • d. Footboard (YES) • A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

A. • A lack of rapid eye movement (REM) sleep
 • B. Sudden attacks of sleep (yes)
 • C. Hallucinations at the onset of sleep (YES)
 • D. Sleep apnea
 • E. The urge to move the legs when trying to sleep • A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?

 • A. Hypotension
 • B. Numbness
 • C. Shivering (yes)
 • D. Reduced blood viscosity • A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

 • A. Check that the client lifts the walker and then places it down in front of her. (YES) • B. Walk in front of the client to guide her in moving the walker
 • C. Have the client move one leg forward with the walker
 • D. Make sure that the upper bar of the walker is level with the client's waist • A client with a decreased LOC is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which is a priority action by the nurse?

 • a. Observe respiratory status
 • b. Elevate HOB 30-45deg
 • c. Monitor I&O q8h
 • d. Check residual volume q4-6h • A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?

 • A. Determine if the client can bear weight.
 • B. Place a transfer belt on the client
 • C. Position the bed at an appropriate height
 • D. Assist the client to a seated position • a nurse is caring for a client who is receiving enteral feedings through an NG tube? Before administering a feeding the nurse should measure the gastric residual for which of the following purposes? • To confirm the placement of the NG tube • To remove gastric acid that might cause dyspepsia • To determine the clients electrolyte balance • To identify delayed gastric emptying • Which strategies should the nurse teach to minimize back strain and avoid repeated episodes of low back pain? (AVOID PROLONGED SITTING, TRY PADDED SHOES, NO TO THE SIDE LYING POSITION)

 • a. Avoid prolonged sitting
 • b. Apply heat 10min/hr
 • c. Sleep side-lying with flexed knees
 • d. Sleep on a soft mattress
 • e. Try padded shoe insoles • A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?

 • A. Auscultate breath sounds at least every 2 hr. • B. Perform range-of-motion (ROM) exercises at least two to three times daily.
 • C. Make sure the client has an intake of 2,000 to 3,000 ml of fluid per day.
 • D. Apply anti-embolic stockings. • A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? • The nurse initiates the feeding after aspirating 50 mL of gastric residual • The nurse irrigates the NG tube with tap water after feeding • The nurse administers the feeding through a syringe barrel by gravity • The nurse allows the client to rest in a supine position during feedingA nurse receives report at the start of shift. Who should the nurse plan to see first?

 • a. A client who had a Cesarean birth 4h ago and reports pain (YES)
 • b. A client with preeclampsia with a BP of 138/90
 • c. A client who had a vaginal birth 24h ago and reports no bleeding
 • d. A client who is scheduled for discharge following laparoscopic tubal ligation • A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

 • A. Temporary urinary retention (YES)
 • B. Urinary frequency for several days
 • C. Blood-tinged urine
 • D. Highly concentrated urine • A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

 • A. Reposition the client every 3 hr
 • B. massage bony prominences to promote circulation
 • C. Provide the client with a diet high in protein (YES)
 • D. Apply cornstarch to keep the skin dry • A nurse is teaching a parent of an infant who has HF about meeting the infant's nutritional needs. Which of the following statements indicates understanding of teaching?

 • 1. "I will feed my baby on a schedule every 4 hrs"
 • 2. "I will add Polycose to each of my baby's bottles" (NO)
 • 3. "I will allow my baby to take as much time as needed to finish bottle" (YES)
 • 4. "I will limit my babies crying to 15 mins prior to each feeding: • Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (select all that apply)

 • a. Client with lactose intolerance
 • b. Client who had a cerebrovascular accident(YES)
 • c. Client who is 4h postop following leg amputation with general anesthesia (YES)
 • d. Client who has had prolonged diarrhea
 • e. Client who has had radiation therapy for head and neck cancer(YES) • A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

 • a. Reposition the client
 • b. Administer the medication
 • c. Determine the location of the pain (YES)
 • d. Review the effects of the pain medication • Which action should the nurse take for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury?

 • a. Apply bag for 30min at a time (NO)
 • b. Reapply bag 30 min after removing it (YES)
 • c. Allow room for air inside bag
 • d. Place bag directly on skin • A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies? • “Skeletal traction has less risk for infection than skin traction” • “Clients with skin traction have more mobility than those with skeletal traction” • “Skeletal traction is better than skin traction for reducing a fracture” (YES) • “Clients with skin traction have more discomfort than those with skeletal traction” • A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. This is most likely an indication of which of the following conditions?

 • a. Upper respiratory infection
 • b. Pulmonary edema
 • c. Atelectasis (YES)
 • d. Delayed gastric emptying • A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? • Decrease the client's fluid intake Increase the client’s saturated fat intake • Increase the client’s sodium intake • Decrease the client’s carbohydrate intakeThe nurse should base pain management interventions for a postop patient primarily on which method of determining pain intensity?

 • a. Vital sign measurement
 • b. Client's self-report of pain severity (YES)
 • c. Visual observation for nonverbal signs of pain
 • d. Nature and invasiveness of procedure • A parent tells the nurse in the pediatric clinic that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that this client is at risk for which of the following disorders?

 • A. Iron-deficiency anemia (YES)
 • B. Rickets
 • C. Diabetes mellitus
 • D. Obesity • An older adult client in a long-term care facility had a cerebrovascular accident (CVA) 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility? A. Reddened area over the sacrum B. Stiffness in the lower extremities (yes STIFFNESS IN LOWER EXTREMITIES) C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds [Show More]

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