Question

A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Determine the client's preferences.

Rationale :

🛁 Understanding the client’s preferences promotes client-centered care and encourages participation in ADLs, which supports autonomy and dignity.

🛁 Tailoring care to preferences can increase the client’s motivation and cooperation during assistance.

🛁 Postponing care or eliminating non-essential activities can lead to decreased independence and potential decline in function.

🛁 Informing the client about timing is important but comes after assessing their preferences to individualize care.

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Answer 2

Correct Answers:

Replace the shower head with a hand-held nozzle.

Rationale :

🚿 A hand-held shower nozzle increases safety and accessibility by allowing the older adult to control water direction and reduce the risk of slips and falls while bathing.

🚿 It helps clients with limited mobility or balance issues maintain independence and reduces strain.

🚿 Throw rugs can increase fall risk and should be avoided or secured.

🚿 The recommended safe water heater temperature is below 49°C (120°F) to prevent burns, so 54.5°C (130°F) is too high.

🚿 A thermostat set at 26°C (79°F) may cause overheating and dehydration risk in older adults; a lower, comfortable setting is advised.

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Answer 3

Correct Answers:

Determine the pH level of gastric contents.

Rationale :

🩺 Checking the pH of gastric contents is the priority to verify correct nasogastric tube placement before administering feedings.

🩺 Ensuring the tube is in the stomach reduces the risk of aspiration pneumonia and other complications.

🩺 Only after confirming placement should the nurse proceed to flush the tube, measure residuals, and prepare formula for feeding.

🩺 This step is essential for client safety and is always performed before feed administration.

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Answer 4

Correct Answers:

Test the alarm and battery of the device.

Rationale :

🔔 After explaining the procedure, the nurse should test the bed alarm and battery to ensure the device functions properly before applying it.

🔔 This step helps prevent device failure, which could lead to missed alerts and increased fall risk.

🔔 Only after confirming proper function should the nurse apply the sensor pad and instruct the client on its use.

🔔 Documenting and instructing the client are important but occur after ensuring the alarm works.

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Answer 5

Correct Answers:

63

Rationale :

🧪 Total volume: 250 mL

⏳ Time: 4 hours

➗ Flow rate (mL/hr) = Total volume ÷ Time

= 250 mL ÷ 4 hr

= 62.5 mL/hr

🔢 Rounded flow rate: 63 mL/hr

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Answer 6

Correct Answers:

"Tell me how I can best help you right now."

Rationale :

🗣️ This response demonstrates empathy and active listening, allowing the client to express needs and feelings in a supportive environment.

🗣️ It empowers the client by involving her in the care plan and prioritizing her immediate concerns.

🗣️ Avoiding the topic or dismissing the client’s experience can invalidate feelings and hinder trust.

🗣️ Offering unsolicited advice about living arrangements may not respect the client’s autonomy or preferences.

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Answer 7

Correct Answers:

Osteoarthritis

Rationale :

🦴 Obesity increases the mechanical stress on weight-bearing joints such as knees and hips, accelerating cartilage breakdown and contributing to osteoarthritis development.

🦴 Excess weight also promotes inflammation, which can worsen joint degeneration.

🦴 Emphysema is primarily related to smoking and lung issues, not obesity.

🦴 Hyperthyroidism and hypotension are not typically caused by obesity; in fact, obesity is more commonly linked to hypertension.

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Answer 8

Correct Answers:

The website for the Cystic Fibrosis Foundation

Rationale :

🌐 The Cystic Fibrosis Foundation’s website is a reliable, evidence-based source that provides accurate, up-to-date information on cystic fibrosis, including treatment, management, and support resources.

🌐 Information from a reputable foundation ensures educational content is medically sound and trustworthy.

🌐 Parents of children and assistive personnel may offer anecdotal experiences but not always comprehensive or evidence-based knowledge.

🌐 Commercial websites ending in ".com" may have biased or unverified information, so they are not the most reliable for health education.

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Answer 9

Correct Answers:

Flush both arms and hands with cool running water right away.

Rationale :

💧 Immediate flushing of the affected skin with cool running water helps remove the plant’s oil (urushiol) that causes the allergic reaction in poison ivy contact dermatitis.

💧 This action minimizes absorption of the irritant and reduces the severity of the rash and itching.

💧 Using oils like olive or mineral oil can spread the urushiol, worsening the reaction.

💧 Scrubbing with hot water or antibacterial soap can irritate the skin further and is not recommended.

💧 Poison ivy contact dermatitis is not contagious, so avoiding contact with family members is unnecessary.

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Answer 10

Correct Answers:

Pinch the tubing below the injection port prior to administration.

Rationale :

💉 Pinching the IV tubing below the injection port prevents the medication from being diluted by the continuous IV fluid and ensures the full dose of fentanyl is delivered rapidly into the bloodstream.

💉 This technique helps the medication reach the circulation quickly for effective pain relief.

💉 Flushing with heparin is not appropriate for a sodium chloride infusion; normal saline is used if flushing is required.

💉 The medication should be injected into the port farthest from the client to allow proper mixing.

💉 Fentanyl IV bolus should be administered slowly over 1 to 2 minutes to reduce adverse effects, not over 10 seconds.

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ATI RN Concept Based Assessment level 1

No.

1 :
A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

2 :
A nurse is teaching an older adult client about safety in the home environment. Which of the following actions should the nurse recommend?

3 :
A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

4 :
A nurse is preparing to apply a bed alarm for a client who is at risk for falls and attempts to get out of bed without assistance. After explaining the procedure to the client, which of the following actions should the nurse take next?

5 :
A nurse is preparing to administer 0.9% sodium chloride 250 mL. IV to infuse over 4 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse in a community health center is consulting with a client who lost her home in a fire a few days ago. Which of the following responses should the nurse make?

7 :
A nurse is assessing a client who is obese. The nurse should identify the client as at risk for which of the following conditions?

8 :
A nurse is preparing a teaching program for the parents of a toddler who has a new diagnosis of cystic fibrosis. From which of the following sources should the nurse obtain information?

9 :
A nurse in a provider's office receives a telephone call from the parent of a preschooler whose hands and arms were in contact with poison ivy 5 min ago. Which of the following instructions should the nurse give the parent to minimize the manifestations of this type of contact dermatitis?

10 :
A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?

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ATI RN Concept Based Assessment level 1

No.

1 : A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

2 : A nurse is teaching an older adult client about safety in the home environment. Which of the following actions should the nurse recommend?

3 : A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

4 : A nurse is preparing to apply a bed alarm for a client who is at risk for falls and attempts to get out of bed without assistance. After explaining the procedure to the client, which of the following actions should the nurse take next?

5 : A nurse is preparing to administer 0.9% sodium chloride 250 mL. IV to infuse over 4 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6 : A nurse in a community health center is consulting with a client who lost her home in a fire a few days ago. Which of the following responses should the nurse make?

7 : A nurse is assessing a client who is obese. The nurse should identify the client as at risk for which of the following conditions?

8 : A nurse is preparing a teaching program for the parents of a toddler who has a new diagnosis of cystic fibrosis. From which of the following sources should the nurse obtain information?

9 : A nurse in a provider's office receives a telephone call from the parent of a preschooler whose hands and arms were in contact with poison ivy 5 min ago. Which of the following instructions should the nurse give the parent to minimize the manifestations of this type of contact dermatitis?

10 : A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?

1 :
A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

2 :
A nurse is teaching an older adult client about safety in the home environment. Which of the following actions should the nurse recommend?

3 :
A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

4 :
A nurse is preparing to apply a bed alarm for a client who is at risk for falls and attempts to get out of bed without assistance. After explaining the procedure to the client, which of the following actions should the nurse take next?

5 :
A nurse is preparing to administer 0.9% sodium chloride 250 mL. IV to infuse over 4 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse in a community health center is consulting with a client who lost her home in a fire a few days ago. Which of the following responses should the nurse make?

7 :
A nurse is assessing a client who is obese. The nurse should identify the client as at risk for which of the following conditions?

8 :
A nurse is preparing a teaching program for the parents of a toddler who has a new diagnosis of cystic fibrosis. From which of the following sources should the nurse obtain information?

9 :
A nurse in a provider's office receives a telephone call from the parent of a preschooler whose hands and arms were in contact with poison ivy 5 min ago. Which of the following instructions should the nurse give the parent to minimize the manifestations of this type of contact dermatitis?

10 :
A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?