Question

A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

Answer 1

Correct Answers:

Mark the edges of steps.

Rationale :

🟧 Marking the edges of steps with brightly colored or high-contrast tape increases visibility and helps prevent falls for clients with visual impairment.

🟧 This visual cue allows the client to detect depth changes, reducing the risk of injury when climbing or descending stairs.

🟧 Other environmental modifications like proper lighting and clear walkways further enhance home safety.

🟧 Placing throw rugs or leaving doors ajar creates tripping hazards, especially for visually impaired clients.

🟧 Educating clients about hazard reduction is a critical component of fall prevention strategies.

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Answer 2

Correct Answers:

Store opened insulin vials at room temperature for up to 4 weeks.

Rationale :

🟥 Opened insulin vials can be stored at room temperature for up to 28 days, which preserves stability and ensures proper dosage delivery.

🟥 Storing insulin outside of the refrigerator after opening prevents discomfort from cold injections.

🟥 Freezing insulin destroys its effectiveness, and warming vials improperly can alter the insulin’s structure.

🟥 Crystals in the vial should be resolved by gently rolling, not heating.

🟥 Proper storage helps ensure the insulin remains safe and effective throughout its use.

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Answer 3

Correct Answers:

Suction the tracheostomy tube.

Rationale :

🟩 Suctioning the tracheostomy tube should be the first priority to ensure that the airway is clear and not obstructed by secretions.

🟩 Maintaining a patent airway is critical before performing other tasks such as dressing changes or auscultation.

🟩 If secretions are left in the airway, it can lead to hypoxia, infection, or respiratory distress.

🟩 Suctioning also improves breath sounds and facilitates effective ventilation.

🟩 Once the airway is secured, other aspects of care can be completed more safely and effectively.

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Answer 4

Correct Answers:

"I will notify emergency response if I have sudden jaw pain."

Rationale :

🟦 Jaw pain is an atypical but critical sign of a myocardial infarction (MI), particularly in women.

🟦 Recognizing this as an emergency allows for rapid medical intervention, which can prevent further myocardial damage.

🟦 Teaching clients to report such symptoms promptly improves cardiac survival rates.

🟦 Angina education must include both typical and atypical symptoms, such as jaw, neck, or shoulder discomfort.

🟦 The client’s understanding demonstrates appropriate recognition of a life-threatening condition.

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Answer 5

Correct Answers:

Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction.

Rationale :

🟥 Skeletal traction requires adequate weight to maintain alignment and promote bone healing.

🟥 4.5 kg (10 lb) is a standard minimum for effective skeletal traction unless otherwise prescribed.

🟥 Weights should never be removed or adjusted without an order, as doing so can cause misalignment or worsen the injury.

🟥 Maintaining the correct setup also helps in pain control and prevents further injury.

🟥 The nurse’s role includes routine monitoring to ensure continuous traction effectiveness and patient safety.

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Answer 6

Correct Answers:

A suction machine

Rationale :

🟫 A suction machine is essential during seizure precautions to manage airway clearance if the client vomits or has excessive secretions.

🟫 During or post-seizure, clients are at risk for aspiration, and suctioning can prevent respiratory complications.

🟫 Other equipment, such as padded tongue blades, can cause harm and are not recommended by seizure safety guidelines.

🟫 Preparing the environment helps ensure rapid, safe response if a seizure occurs.

🟫 Airway maintenance is the top priority during seizure episodes.

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Answer 7

Correct Answers:

Swallow the medication whole.

Rationale :

🟪 Sustained-release (SR) tablets like diltiazem must be swallowed whole to maintain the extended drug release profile.

🟪 Crushing or chewing these tablets can result in dose dumping, leading to toxicity or loss of effect.

🟪 Grapefruit juice should be avoided with diltiazem as it can interfere with cytochrome P450 metabolism, increasing serum drug levels.

🟪 It is important to explain why proper administration matters, especially in long-term medication regimens like antihypertensives.

🟪 The nurse ensures medication safety and therapeutic consistency through clear instructions.

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Answer 8

Correct Answers:

Limit fluid intake during meals.

Rationale :

🟨 Clients with COPD often experience early satiety and dyspnea when eating.

🟨 Limiting fluid intake during meals helps reduce stomach fullness, making it easier to eat more solid, nutritious foods.

🟨 Fluids can be consumed between meals to stay hydrated without affecting meal volume.

🟨 Nutritional status is critical in COPD to maintain respiratory muscle function.

🟨 Educating clients on mealtime adjustments supports improved energy and reduced breathlessness.

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Answer 9

Correct Answers:

Asthma

Rationale :

🟥 Propranolol is a non-selective beta-blocker that blocks both beta-1 (cardiac) and beta-2 (pulmonary) receptors.

🟥 In clients with asthma, blocking beta-2 receptors can lead to bronchoconstriction and asthma exacerbation.

🟥 This makes propranolol contraindicated for anyone with reactive airway diseases.

🟥 Alternative antihypertensive medications like cardioselective beta-blockers or calcium channel blockers may be safer.

🟥 Nurses should always review respiratory history before administering beta-blockers.

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Answer 10

Correct Answers:

Recommend consumption of cold items.

Rationale :

🟩 Stomatitis causes oral pain and inflammation, often as a side effect of chemotherapy.

🟩 Cold foods or beverages help numb oral tissues, reduce inflammation, and promote comfort.

🟩 Clients should avoid spicy, acidic, or hot items that may irritate the mucosa further.

🟩 Alcohol-based mouthwashes should also be avoided, as they can worsen mucosal damage.

🟩 Dietary changes and gentle oral care improve healing and quality of life during cancer treatment.

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ATI PN Adult Medical Surgical 2023

No.

1 :
A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

2 :
A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include?

3 :
A nurse is caring for a client who has a tracheostomy. When providing tracheostomy care, which of the following actions should the nurse perform first?

4 :
A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

5 :
A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who requires seizure precautions. Which of the following equipment should the nurse place at the client's bedside?

7 :
A nurse is reinforcing teaching with a client who is taking diltiazem sustained-release tablets for hypertension. Which of the following instructions should the nurse include?

8 :
A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

10 :
A nurse is caring for a client who is receiving treatment for cancer and is experiencing stomatitis. Which of the following actions should the nurse take to help manage the condition?

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ATI PN Adult Medical Surgical 2023

No.

1 : A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

2 : A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include?

3 : A nurse is caring for a client who has a tracheostomy. When providing tracheostomy care, which of the following actions should the nurse perform first?

4 : A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

5 : A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?

6 : A nurse is caring for a client who requires seizure precautions. Which of the following equipment should the nurse place at the client's bedside?

7 : A nurse is reinforcing teaching with a client who is taking diltiazem sustained-release tablets for hypertension. Which of the following instructions should the nurse include?

8 : A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?

9 : A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

10 : A nurse is caring for a client who is receiving treatment for cancer and is experiencing stomatitis. Which of the following actions should the nurse take to help manage the condition?

1 :
A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

2 :
A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include?

3 :
A nurse is caring for a client who has a tracheostomy. When providing tracheostomy care, which of the following actions should the nurse perform first?

4 :
A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

5 :
A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who requires seizure precautions. Which of the following equipment should the nurse place at the client's bedside?

7 :
A nurse is reinforcing teaching with a client who is taking diltiazem sustained-release tablets for hypertension. Which of the following instructions should the nurse include?

8 :
A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

10 :
A nurse is caring for a client who is receiving treatment for cancer and is experiencing stomatitis. Which of the following actions should the nurse take to help manage the condition?