ATI one
A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?
To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Question: Which of the following food or beverage selections by the client indicates a need for further teaching? Person of Focus: The client who has been taught about a 2,000 mg sodium-restricted diet Key Words: 2,000 mg sodium-restricted diet, selections, need for further teaching So, the question is asking which of nutritional selections is not appropriate for a client prescribed a 2,000 mg sodium-restricted diet. This is a negatively worded, traditional multiple choice item, which means there are four options. Of these options, three are accurate, called the distracters, and one is inaccurate, which is the key because the item is negatively worded. Because the question indicates there is only one correct answer, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 3/4 cup of canned tomato juice is correct. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.
A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective?
"I feel very relaxed." To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam preoperatively. Question: Which of the following statements by the client indicates the medication has been effective? Person of Focus: The client who received the preoperative dose of lorazepam Key Words: administers, lorazepam (Ativan), preoperatively, effective So, the question is asking which client statement indicates the medication has been effective. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you have to review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. "I feel very relaxed" is correct. Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective.
A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief?
Bargaining o answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is scheduled for a biopsy of a tumor located in her left lower lobe. The client states, "I will quit smoking if the results don't come back positive for cancer." Question: This statement indicates the client is in which of the following stages of grief? Person of Focus: The client scheduled for the biopsy of a lung tumor Key Words: tumor, left lower lobe of lung, "I will quit if" So, the question is asking which of the stages of grief is client is in. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.
A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?
Partial thickness skin loss To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is immobile and has developed a pressure ulcer. Question: Which of the following characteristics is associated with a stage II pressure ulcer? Person of Focus: The client who has developed a pressure ulcer Key Words: pressure ulcer, characteristics, stage II So, the question is asking which of the characteristics is associated with a stage II pressure ulcer. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.
A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?
Stand close to the client. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who needs assistance moving from the bed to a chair. Question: The nurse should take which of the following actions to prevent a lift injury? Person of Focus: The client who is being transferred from the bed to a chair Key Words: transfer, prevent, lift injury So, the question is asking which of the actions the nurse should take to prevent sustaining an injury when transferring a client from the bed to a chair. This is a positively worded, traditional multiple choice item, which means there will be four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Stand close to the client is correct. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back.
A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?
To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. Question: How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose? Person of Focus: The nurse who is instructing the parents about administering diphenhydramine. Key Words: diphenhydramine 25 mg, available is diphenhydramine 12.5 mg / 5 mL syrup, teaspoons per dose. So, the question is asking the number of teaspoons of diphenhydramine the nurse should teach the parents to administer for each dose. This is a fill in the blank item, requiring a numerical calculation. Next you should set up the equation to solve this type of problem and calculate the correct dose. To answer correctly, only a number should be entered in the provided space. To answer this calculation fill in the blank question, the nurse should be able to convert 10 mL of medication into a household measurement (teaspoon). The child needs to receive 10 mL of diphenhydramine. There is 5 mL in one teaspoon, so 10 mL = (10 / 5) = 2 tsp. Therefore, you should enter the numeral 2 in the box without any units or spacing devices. STEP 1: What is the dose needed? Dose needed = Desired; 25 mg STEP 2: What is the dose available? Dose available = Have; 12.5 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 25 mg x 5 mL / 12.5 = x mL; 25 x 5 / 12.5 = 125 ÷ 12.5 = 10 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 10 mL / x; 5x = 10; x = 2 tsp. STEP 6: Reassess to determine if the amount to be given makes sense. If there are 12.5 mg/mL and the prescribed amount is 25 mg, it makes sense to give 10 mL, which equals 2 tsp. The nurse should teach the parents to administer diphenhydramine 2 tsp per dose.
A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?
1 1/2 inch To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Question: Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? Person of Focus: The nurse who is preparing to administer an IM injection Key Words: IM injection, needle lengths, ventrogluteal muscle So, the question is asking which of the needle lengths is appropriate for administering an injection in the ventrogluteal muscle. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.
