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ATI PN Fundamentals (B) with Rationales: Questions & Answers: Latest Updated A+ Score Solution

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A nurse in a provider's office is providing care for a middle adult client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? a. reduce intake of c... alcium-rich foods b. use sunscreen with skin protection factor (SPF of 8 c. take vitamin D supplements d. use a tanning bed 2 hr weekly (Ans- c. take vitamin D supplements -the human body requires sunlight exposure to synthesize vitamin D. Therefore, the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D. A nurse is caring for an older adult client who has advanced rheumatoid arthritis but seldom requests pain medication. Which of the following actions should the nurse take? a. question the client using the FACES pain scale b. observe the client for nonverbal indications of pain c. wait for the client to report pain before offering medication d. take the client's vital signs to determine if he is experiencing pain (Ans- b. observe the client for nonverbal indications of pain -The nurse should identify that an older adult might refrain from reporting pain, but can still display nonverbal signs of pain, such as grimacing, restlessness, and insomnia A nurse is checking a client's muscle strength. Which of the following techniques should the nurse use? a. the nurse holds the sides of the client's head and attempts to turn it while the client resists b. the client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders c. the nurse attempts to straighten the client's leg as the client offers resistance while in a seated position d. the client holds her arms out and attempts to lower them while the nurse applies upward pressure (Ans- b. the client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders -The nurse is checking the strength of the trapezius muscles of the shoulders with this technique A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? a. complicated grief b. maturational loss c. disenfranchised grief d. actual loss (Ans- d. actual loss -the nurse should identify that the client's comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear, or know an object, another person, or a part of themselves, such as a loss of a body part. A nurse is caring for a client who is dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions? a. orthopneic b. dorsal recumbent c. sims' d. prone (Ans- a. orthopneic -The nurse should assist the client into the orthopneic position by having the client sit upright either in bed or in a chair and lean forward. This position allows maximal chest expansion and facilitates breathing. A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? a. arrange personal items on a table at the foot of the client's bed b. place the back of the bedside commode next to the client's bed c. raise four side rails on the client's bed during the night d. put the client's bed in the lowest position. (Ans- d. put the client's bed in the lowest position. -The nurse should place the client's bed in the lowest position and lock the wheels to reduce the risk for falls A nurse is planning to administer medication to a client who has a Clostridium difficile infection. TO prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? a. clean hands with an alcohol-based hand rub immediately after removing gloves b. remove the cover gown in the client's room after providing care c. place the client in a room with negative-pressure airflow d. wear a mask when administering oral medications to the client (Ans- b. remove the cover gown in the client's room after providing care -The nurse should initiate contact precautions for clients who have a C. difficile infection. Contact precautions include the removal of the cover gown and other personal protective equipment inside the client's room to prevent the spread of infection. A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? a. the client reports an incisional pain level of 7 on a scale of 0 to 10 b. the client reports increased nausea and chills c. the client has an oral temperature of 39 C (102.2F) d. the client has redness and warmth in his calf (Ans- d. the client has redness and warmth in his calf -When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is redness and warmth in a client's calf, which can indicate the presence of a thrombus. If it moves from the vein to the heart, brain, or lungs, it can cause life-threatening [Show More]

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