which of the following action would be of highest priority with regards to the external shunt
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Nursing Elites

ATI RN

ATI Nutrition Practice Test A 2019

1. Which of the following actions would be of highest priority with regards to the external shunt?

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

2. Transmission of HIV from an infected individual to another person occurs:

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. Why does Anita stand in front of the mirror while performing a Breast Self-Examination (BSE)?

Correct answer: C

Rationale: When performing a Breast Self-Examination (BSE), one of the reasons for standing in front of a mirror is to observe the size and contour of the breast (Choice C). This helps in identifying any visible changes or abnormalities such as dimpling, puckering, or changes in the size and shape of the breasts. While unusual discharges (Choice A) and thickness or lumps (Choice D) can be part of the changes a person might notice during a BSE, these are typically identified by palpation or by squeezing the nipple for discharge, not by just looking in the mirror. Choice B, checking for obvious malignancy, is too vague and not specific enough as malignancy is often not visible to the naked eye.

4. The goal of remotivation therapy is to facilitate:

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

5. A client with chronic pancreatitis is receiving discharge teaching from a nurse. Which of the following statements should the nurse make?

Correct answer: B

Rationale: In chronic pancreatitis, it is important to increase protein intake to support healing and prevent malnutrition. Choice A is incorrect because decreasing caloric intake during abdominal pain may lead to further nutritional deficiencies. Choice C is incorrect as increasing fat intake can exacerbate symptoms due to the impaired fat digestion in chronic pancreatitis. Choice D is incorrect as alcohol should be completely avoided in chronic pancreatitis to prevent further damage to the pancreas.

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