a nurse is preparing to perform tracheostomy care for a client which of the following actions should the nurse take first
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

2. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider instruct the client to avoid?

Correct answer: C

Rationale: The correct answer is C. Bacon is high in sodium, which can elevate blood pressure levels. Clients with hypertension should avoid high-sodium foods like bacon to help manage their blood pressure. Choices A, B, and D are healthier options compared to bacon and can be included in a balanced diet for someone with hypertension. Bananas are a good source of potassium, which can help in managing blood pressure. Carrots are low in sodium and high in fiber, making them a heart-healthy choice. Chicken breast is a lean protein option that is beneficial for individuals with hypertension.

3. What is the appropriate intervention for a patient with hypertension refusing medication?

Correct answer: A

Rationale: The correct answer is A: Educate the patient on the importance of medication. Providing education to the patient is crucial in promoting understanding of the condition and the necessity of medication. By enhancing the patient's knowledge, healthcare providers can empower them to make informed decisions regarding their health. Choice B, respecting the patient's decision, may not be appropriate in this scenario as untreated hypertension can lead to serious complications. Choice C, informing the healthcare provider, is important but should be done after attempting to educate the patient. Choice D, exploring alternative treatment options, may be considered if the patient has concerns or side effects related to the medication, but initially, educating the patient about the importance of medication is key.

4. A nurse is assessing a school-age child who has a urinary tract infection (UTI). Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Enuresis is the correct finding to expect in a school-age child with a urinary tract infection. Enuresis, or involuntary urination, is a common symptom of UTIs in children. Periorbital edema (Choice A) is not typically associated with UTIs. Decreased frequency of urination (Choice B) is less likely in UTIs as there is often an increased urge to urinate. Diarrhea (Choice D) is not a common symptom of UTIs and is more indicative of gastrointestinal issues.

5. A nurse is assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.

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