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PN ATI Capstone Fundamentals Quiz
1. A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?
- A. Speak loudly to the client
- B. Use written communication to assist with communication
- C. Avoid eye contact while speaking
- D. Use sign language without an interpreter
Correct answer: B
Rationale: The correct action for the nurse to take when assessing a client with hearing loss is to use written communication. This method helps ensure effective communication and that the client understands the information being conveyed. Speaking loudly may not be helpful and can be perceived as rude. Avoiding eye contact can hinder communication and appear disrespectful. Using sign language without an interpreter may not be appropriate if the client does not understand sign language.
2. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.
3. A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct answer: A
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration, which is crucial in managing the client's safety during a seizure. Calling for help is important but ensuring the client's immediate safety by positioning them correctly takes precedence. Protecting the client's head can be done concurrently while positioning the client. Restraint is not appropriate during a seizure as it can lead to injuries and complications.
4. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct answer: B
Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.
5. A client is reviewing information about advance directives with a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind at any time.
- B. I have a living will that outlines my wishes when I am unable to make a decision.
- C. I need to inform my family about my wishes.
- D. I don’t need to worry about advance directives right now.
Correct answer: B
Rationale: The correct answer is B because having a living will indicates that the client understands and has documented their wishes regarding medical treatment when they are unable to make decisions. Choice A is incorrect because while it's true that clients can change their minds about advance directives, it doesn't specifically indicate an understanding of the teaching provided. Choice C is important but doesn't directly show if the client understands advance directives. Choice D is incorrect because it dismisses the importance of advance directives, indicating a lack of understanding.
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