the nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip it is most important for the nurse to include wh
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?

Correct answer: D

Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding an infant with a cleft lip using a newborn nipple while in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not typically used on suture sites due to its cytotoxic effects. Choice C is incorrect because placing the infant in the prone position after feeding can also increase the risk of aspiration.

2. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

Correct answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

3. The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of GOD). Which nursing action(s) are most appropriate in terms of providing for the dietary needs of this client? Select all that apply.

Correct answer: B

Rationale: The correct answer is B. Seventh Day Adventists typically avoid caffeine and pork due to religious dietary restrictions. Providing snacks between meals (choice A) is not specifically related to the dietary needs of this client. While removing coffee from the breakfast tray (choice C) aligns with the client's dietary restrictions, ensuring no pork on the dinner tray (choice D) is redundant as it is already covered in the correct answer. Therefore, choices C and D are not necessary to include as separate options.

4. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

5. A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit?

Correct answer: C

Rationale: In catatonic schizophrenia, clients commonly exhibit immobile posturing, where they may maintain a fixed position for extended periods. This could include holding rigid poses or remaining motionless. Choice A, 'Crying,' is not typically associated with catatonic schizophrenia. Choice B, 'Self-mutilation,' refers to a different behavior seen in some mental health conditions but is not a characteristic feature of catatonic schizophrenia. Choice D, 'Repetitive activities,' does not align with the typical presentation of catatonic schizophrenia, which is characterized by motor abnormalities such as immobility rather than engaging in purposeful repetitive movements.

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