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A nurse is caring for a client who has bilateral cats on her hands. Which of
the following actions should the nurse take when assisting the client with
feeding?
A.Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides
the client with the nurse’s full attention during the feeding
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B.Order pureed foods
-incorrect: Without any mouth or throat injuries that make chewing or
swallowing difficult, the client should be served foods of an appropriate variety
of textures. Pureed foods are for clients who cannot chew, have difficulty
swallowing, or do not have teeth.
C.Make sure feedings are provided at room temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
D.Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client
fluids after every 3 or 4 mouthfuls. However, there is no indication that this client
is unable to communicate. Therefore, the client should tell the nurse when she
would like a drink.
A nurse is administering an IM injection to a 5-month-old infant. Which of
the following injection sites should the nurse use?
A.Deltoid
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of
medication for children 18 months of age or older, but its proximity to several
nerves and arteries make it a riskier choice.
B.Ventrogluteal
-incorrect: This is a safe site for IM injections for clients older than 7 months.
C.Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM
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injections for infants and children.
D.Dorsogluteal
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve
and the superior gluteal nerve and artery.
A nurse is caring for a client who has major fecal incontinence and reports
irritation in the perianal area. Which of the following actions should the nurse
take first?
A.Apply a fecal collection system
-incorrect: The nurse should apply a fecal collection system to divert the feces
away from the area of skin irritation; however, there is another action the nurse
should take first.
B.Apply a barrier cream
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown
in the perianal area from the feces; however, there is another action the nurse
should take first.
C.Cleanse and dry the area
-incorrect: The nurse should cleanse and dry the perianal area to decrease
skin irritation; however, there is another action the nurse should take first.
D.Check the client’s perineum
-The nurse should apply the nursing process priority-setting framework to plan
care and prioritize nursing actions. Each step of the nursing process builds on the
previous step, beginning with an assessment or data collection. Before the nurse
can formulate a plan of action, implement a nursing intervention, or notify a
ATI Fundamentals Proctored Exam | Questions and
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provider of a change in the client’s status, the nurse must first collect adequate data
from the client. Assessing or collecting additional data will provide the nurse with
knowledge to make an appropriate decision. The priority nursing action is for the
nurse to collect more data by assessing the area of irritation.
ATI Fundamentals Proctored Exam | Questions and
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