ATI YCOMPREHENSIVE Y REAL YEXAM YWELL YELABORATED Y195+ Y QUESTIONS YAND
YDETAILED
ANSWERS Y WITH Y RATIONAL Y 2024 YUPDATE YALREADY YA YGRADE.
1. A Ynurse Yin Ya YLTC Yfacility Ynotices Ya Yclient Ywho Yhas YAlzheimer’s Ydisease Ystanding Yat Ythe Yexit Ydoor Yat Ythe Yend Yof
Ythe Yhallway. YThe Yclient Yappears Yto Ybe Yanxious Y& Yagitated. YWhat Yaction Yshould Ythe Ynurse Ytake?
ANS: YEscort Ythe Yclient Yto Ya Yquiet Yarea Yon Ythe Ynursing Yunit.
- A Yclient Yc YAlzheimer Yexperiences Ychronic Yconfusion. YGuiding Ythe Yclient Yto Ya Yquiet, Yfamiliar Yarea Ywill Yhelp
Ydecrease Y Yagitation. YThey Ywill Ybe Yunable Yto Yfollow Yinstructions/commands.
2. A Ynurse Yis Yassisting Ywith Ythe Yplan Yof Ycare Yfor Ya Yclient Ywho Yhas Ya Ycontinent Yurinary Ydiversion. YWhich
Yintervention Yshould Ythe Ynurse Yplan Yto Yimplement Yto Yfacilitate Yurinary Yelimination?
ANS: YUse Yintermittent Yurinary Ycatheterization Yfor Ythe Yclient Yat Yregular Yintervals.
- A Ycontinent Yurinary Ydiversion Ycontains Yvalves Ythat Yprevent Yurine Yfrom Yexiting Ythe Ypouch; Ytherefore, Ythe
Ynurse Y Yshould Yplan Yto Yinsert Ya Yurinary Ycatheter Yat Yregular Yintervals Yto Ydrain Yurine Yfrom Ythe Yclient’s
Ypouch.
3. A Ynurse Yis Yassisting Ywith Yan Yeducation Yprogram Yabout Ycar Yrestraint Ysafety Yfor Ya Ygroup Yof Yparents. YWhich
Ystatement Yby Ythe Yparent Yindicates Yan Yunderstanding Yof Ythe Yinstructions?
ANS: Y“My Y12YO Ychild Yshould Yplace Ythe Yshoulder-lap Yseatbelt Ylow Yacross Yhis Yhips.”
- When Ya Ychild Yis Yold Yenough Yto Yonly Yuse Ya Yshoulder-lap Yseatbelt, Yhe Yshould Yplace Yit Ylow Yacross Yhis Yhips Yrather
Ythan Y Yover Ythe Yabdomen Yto Yreduce Yrisk Yfor Yinjury Yduring Ymotor Yvehicle Ycrash.
4. A Ynurse Yis Yreinforcing Yteaching Yabout Ystrategies Yto Ypromote Yeating Ywith Ya Yclient Ywho Yhas YCOPD.
YWhich Yinstructions Yshould Ythe Ynurse Yinclude Yin Ythe Yteaching?
ANS: YDrink Yhigh-protein Yand Yhigh-calorie Ynutritional Ysupplements.
- The Ynurse Yshould Yinstruct Ythe Yclient Yto Ydrink Yhigh-protein Yand Yhigh-calorie Ynutritional Ysupplements Yto
Ymaintain Yrespiratory Ymuscle Yfunction. YCOPD Ycauses Yrespiratory Ystress Ythat Yleads Yto Yhypermetabolism Yand
Ywasting Yof Ythe Yclient’s Ymuscle Ymass.
5. When Yremoving YPPE Yafter Ydirect Ycare Yfor Ya Yclient Ywho Yrequires Yairborne Y& Ycontact Yprecautions, Ywhich
YPPE Yis Yremoved Yfirst?
ANS: YGloves
- The Ygreatest Yrisk Yis Ycontamination Yfrom Ypathogens Ythat Ymight Ybe Ypresent Yon Ythe YPPE; Ytherefore, Ythe
Ypriority Y Yaction Yfor Ythe YAP Yis Yto Yremove Ythe Ygloves, Ywhich Yare Yconsidered Ythe Ymost Ycontaminated.
6. A Ynurse Yis Yinspecting Ythe Yskin Yof Ya Ynewborn. YWhich Yfinding Yshould Ythe Ynurse Yreport Yto Ythe
YPCP? YANS: YGeneralized YPetechiae
- Petechiae Yare Yan Yexpected Yfinding Yover Ythe Ypresenting Ypart Yof Ythe Ynewborn, Ysuch Yas Yon Ythe Yforehead Yin Ya
Ybrow Y Ypresentation, Y& Yalso Yanywhere Yon Ythe Yhead Yof Yinfants Ywho Yhad Ya Ynuchal Ycord, Yw/c Yis Yan Yumbilical Ycord
Yaround Ythe Y Yneck. YHowever, Ypetechiae Yall Yover Ythe Ynewborn’s Ybody Ycan Yindicate Yinfection Yor Ydecreased
Yplatelet Ycount Yand Y Yshould Ybe Yreported Yto Ythe Yprovider.
7. A Ynurse Yis Ycontributing Yto Ya Yteaching Yplan Yfor Ya Ygroup Yof Ymale Yadolescents Yabout Ythe YA/E Yof Yanabolic Ysteroid
,use. YWhich Ymanifestations Yshould Ythe Ynurse Yinclude?
Y
, ANS: YReduced Yheight Ypotential
- Use Yof Yanabolic Ysteroids Yin Yadolescence Ycan Ylead Yto Ypremature Yepiphyseal Yclosure, Ythus Yreducing Yfull
Yheight Y Ypotential. YA/E Yincludes: YLiver Ydisorders, Yhyperlipidemia, Ybreast Yenlargement, Yacne, Yand Yedema.
8. A Ynurse Yis Yreinforcing Yteaching Ywith Yan Yolder Yadult Yclient Ywho Yhas Ysevere YL-sided YHF. YWhich Ystatement Yshould
Ythe Ynurse Ymake?
ANS: YRest Yfor Y15 Yminutes Ybetween Yactivities.
- The Ynurse Yshould Yinstruct Yto Yincrease Yhis Yactivity Ygradually Y& Yto Yrest Yfor Ya Yperiod Yof Y15 Ymin Yif Yhe Ybecomes Ytired.
Clients Ywho Yhave YHF Yshould Ybalance Yactivity Yc Yrest Yto Yreduce Ycardiac Yworkload.
9. A Ynurse Yin Ya YLTC Yfacility Yis Ydocumenting Ythe Ycare Yof Yan Yolder Yadult Yclient. YWhich Yinformation Yshould Ybe
Yincluded Yin Yweekly Ynursing Ycare Ysummary?
ANS: YHydration YStatus
- Older Yadult Yclient Yare Yat Yrisk Yfor Ydehydration. YTherefore, Ythe Ynurse Yshould Ybe Yvigilant Yabout Ymonitoring
Ythe Y Yclient’s Yhydration Ystatus Y& Yinclude Ythis Yinformation Yin Ythe Yweekly Ynursing Ycare Ysummary.
, 10. A Ynurse Yis Ycaring Yfor Ya Yclient Ywho Yhas Ya Yhead Yinjury. YUsing Ythe YGlasgow YComa YScale Yto Ycollect Ydata, Ythe
Ynurse Yshould Yobtain Ywhich Yinformation?
ANS: YMotor YResponse
- The Ynurse Yshould Ycollect Ydata Yabout Ythe Yclient’s Ymotor Yresponse Y& Yassign Ythe Yresponse Ya Yscore Yof Y1-6,
Yaccording Y Yto Ythe YGlasgow YComa YScale.
11. A Yhome Yhealth Ynurse Yis Yreinforcing Yteaching Ywith Ya Yclient Yabout Ythe Yuse Yof Yelastic Ystockings Yto Ydecrease
Yperipheral Yedema. YWhich Yinstruction Yshould Ythe Ynurse Yinclude?
ANS: YApply Ythe Ystocking Yin Ythe Ymorning.
- The Ynurse Yshould Yinstruct Ythe Yclient Yto Yapply Ythe Yelastic Ystocking Yin Ythe Ymorning Yand Yremove Ythem Yat Ythe Yend
Yof Y Ythe Yday Ybefore Ybedtime.
12. A Ynurse Yis Yobtaining Yhealth Yhx Yfrom Ya Yclient Ywho Yis Yscheduled Yto Yundergo Ycardiac Ycatheterization Yin Y2 Ydays.
YWhich Yquestions Yis Ythe Ypriority Yfor Ythe Ynurse Yto Yask?
ANS: Y“Do Yyou Yknow Yif Yyou’re Yallergic Yto Yiodine?”
- The Ygreatest Yrisk Yto Ythe Yclient Yis Yan Yallergic Yreaction Yto Ythe Ycontrast Yagent, Ywhich Ycontains Yiodine.
13. A Ynurse Yis Yplanning Yto Yadminister Ynystatin Yoral Ysuspension Yto Ya Yclient Ywho Yhas Yoral Ycandidiasis. YWhich
Yinstructions Yshould Ythe Ynurse Ygive?
ANS: Y“Hold Ythe Ymedication Yin Yyour Ymouth Yfor Yseveral Yminutes Yprior Yto Yswallowing”
- The Yclient Yshould Yswish Y& Yhold Ythe Yliquid Yin Ythe Ymouth Yfor Yat Yleast Y2 Ymin Yto Yfacilitate Ycontact Yof Ythe
Ymedication Y Ywith Ythe Yorganism. YThe Yclient Yshould Ythen Yswallow Yor Yspit Yout Ythe Ymedication.
14. A Ynurse Yis Ypreparing Yto Ycare Yfor Ythe Yassigned Yclients Yon Yher Yupcoming Yshift. YWhich Ytime Ymanagement
Ystrategies Yshould Ythe Ynurse Yplan Yto Yuse?
ANS: YPrepare Ya Ypriority Ylist Yof Yclient Yneeds Yfor Ythe Yshift.
- The Ynurse Yshould Yprepare Ya Yclient Ypriority-to-do Ylist, Ywhich Ycould Yinclude Yadministering Ytime-critical Ymedications.
This Ywill Yallow Ythe Ynurse Yto Ydetermine Ywhich Yclients Yshould Yreceive Ycare Yfirst.
15. After Ywitnessing Ythe Yconsent, Ywhat Yaction Yshould Ythe Ynurse Ytake
Ynext? YANS: YAsk Yclient Ywhat Yhe Yunderstands Yabout Ythe Yprocedure.
16. Which Ytask Yshould Ythe Ynurse Yassign Yto Yan YAP Yfor Ya Ypt Y2 Ydays Ypost-op Yff YTotal Yknee
Yarthroplasty? YANS: YReapply Yantiembolitic Ystockings Yto Ythe Yclient Yff Ya Yshower.
17. A Ynurse Yis Yreinforcing Yteaching Ywith Ya Yclient Ywho Yis Yreceiving Yradiation Ytherapy Yfor Ycancer Yof Ythe Ylarynx.
YWhich Ystatement Ymade Yby Ythe Yclient Yindicates Yunderstanding Yof Ythe Yteaching?
ANS: Y“I Ywill Ywear Ya Ysoft Yscarf Yaround Ymy Yneck Ywhen YI Yam Youtside”
- Wash Yit Ywith Yplain Ywater Ywithout Ysoap. YNO Yheat Ysource Ytherapy. YOnly Yuse Yelectric Yrazor Yif Ynecessary, Yfor Yshaving.
18. A Ynurse Yis Yusing YFLACC Yscale Yto Ydetermine Ythe Ylevel Yof Ypain Yfor Yan Y11-months-old Yinfant Ywho Ysis Yport-op.
YWhich Yfactor Yshould Ythe Ynurse Yconsider Ywhen Yusing Ythis Ypain Yscale?
ANS: YLevel YOf YActivity
- The Ynurse Yshould Yconsider Ythe Yinfants Ylevel Yof Yactivity Ywhen Yusing YFLACC Ypain Yscale. YThe YFLACC Yis Ydetermined Yby
Y
YDETAILED
ANSWERS Y WITH Y RATIONAL Y 2024 YUPDATE YALREADY YA YGRADE.
1. A Ynurse Yin Ya YLTC Yfacility Ynotices Ya Yclient Ywho Yhas YAlzheimer’s Ydisease Ystanding Yat Ythe Yexit Ydoor Yat Ythe Yend Yof
Ythe Yhallway. YThe Yclient Yappears Yto Ybe Yanxious Y& Yagitated. YWhat Yaction Yshould Ythe Ynurse Ytake?
ANS: YEscort Ythe Yclient Yto Ya Yquiet Yarea Yon Ythe Ynursing Yunit.
- A Yclient Yc YAlzheimer Yexperiences Ychronic Yconfusion. YGuiding Ythe Yclient Yto Ya Yquiet, Yfamiliar Yarea Ywill Yhelp
Ydecrease Y Yagitation. YThey Ywill Ybe Yunable Yto Yfollow Yinstructions/commands.
2. A Ynurse Yis Yassisting Ywith Ythe Yplan Yof Ycare Yfor Ya Yclient Ywho Yhas Ya Ycontinent Yurinary Ydiversion. YWhich
Yintervention Yshould Ythe Ynurse Yplan Yto Yimplement Yto Yfacilitate Yurinary Yelimination?
ANS: YUse Yintermittent Yurinary Ycatheterization Yfor Ythe Yclient Yat Yregular Yintervals.
- A Ycontinent Yurinary Ydiversion Ycontains Yvalves Ythat Yprevent Yurine Yfrom Yexiting Ythe Ypouch; Ytherefore, Ythe
Ynurse Y Yshould Yplan Yto Yinsert Ya Yurinary Ycatheter Yat Yregular Yintervals Yto Ydrain Yurine Yfrom Ythe Yclient’s
Ypouch.
3. A Ynurse Yis Yassisting Ywith Yan Yeducation Yprogram Yabout Ycar Yrestraint Ysafety Yfor Ya Ygroup Yof Yparents. YWhich
Ystatement Yby Ythe Yparent Yindicates Yan Yunderstanding Yof Ythe Yinstructions?
ANS: Y“My Y12YO Ychild Yshould Yplace Ythe Yshoulder-lap Yseatbelt Ylow Yacross Yhis Yhips.”
- When Ya Ychild Yis Yold Yenough Yto Yonly Yuse Ya Yshoulder-lap Yseatbelt, Yhe Yshould Yplace Yit Ylow Yacross Yhis Yhips Yrather
Ythan Y Yover Ythe Yabdomen Yto Yreduce Yrisk Yfor Yinjury Yduring Ymotor Yvehicle Ycrash.
4. A Ynurse Yis Yreinforcing Yteaching Yabout Ystrategies Yto Ypromote Yeating Ywith Ya Yclient Ywho Yhas YCOPD.
YWhich Yinstructions Yshould Ythe Ynurse Yinclude Yin Ythe Yteaching?
ANS: YDrink Yhigh-protein Yand Yhigh-calorie Ynutritional Ysupplements.
- The Ynurse Yshould Yinstruct Ythe Yclient Yto Ydrink Yhigh-protein Yand Yhigh-calorie Ynutritional Ysupplements Yto
Ymaintain Yrespiratory Ymuscle Yfunction. YCOPD Ycauses Yrespiratory Ystress Ythat Yleads Yto Yhypermetabolism Yand
Ywasting Yof Ythe Yclient’s Ymuscle Ymass.
5. When Yremoving YPPE Yafter Ydirect Ycare Yfor Ya Yclient Ywho Yrequires Yairborne Y& Ycontact Yprecautions, Ywhich
YPPE Yis Yremoved Yfirst?
ANS: YGloves
- The Ygreatest Yrisk Yis Ycontamination Yfrom Ypathogens Ythat Ymight Ybe Ypresent Yon Ythe YPPE; Ytherefore, Ythe
Ypriority Y Yaction Yfor Ythe YAP Yis Yto Yremove Ythe Ygloves, Ywhich Yare Yconsidered Ythe Ymost Ycontaminated.
6. A Ynurse Yis Yinspecting Ythe Yskin Yof Ya Ynewborn. YWhich Yfinding Yshould Ythe Ynurse Yreport Yto Ythe
YPCP? YANS: YGeneralized YPetechiae
- Petechiae Yare Yan Yexpected Yfinding Yover Ythe Ypresenting Ypart Yof Ythe Ynewborn, Ysuch Yas Yon Ythe Yforehead Yin Ya
Ybrow Y Ypresentation, Y& Yalso Yanywhere Yon Ythe Yhead Yof Yinfants Ywho Yhad Ya Ynuchal Ycord, Yw/c Yis Yan Yumbilical Ycord
Yaround Ythe Y Yneck. YHowever, Ypetechiae Yall Yover Ythe Ynewborn’s Ybody Ycan Yindicate Yinfection Yor Ydecreased
Yplatelet Ycount Yand Y Yshould Ybe Yreported Yto Ythe Yprovider.
7. A Ynurse Yis Ycontributing Yto Ya Yteaching Yplan Yfor Ya Ygroup Yof Ymale Yadolescents Yabout Ythe YA/E Yof Yanabolic Ysteroid
,use. YWhich Ymanifestations Yshould Ythe Ynurse Yinclude?
Y
, ANS: YReduced Yheight Ypotential
- Use Yof Yanabolic Ysteroids Yin Yadolescence Ycan Ylead Yto Ypremature Yepiphyseal Yclosure, Ythus Yreducing Yfull
Yheight Y Ypotential. YA/E Yincludes: YLiver Ydisorders, Yhyperlipidemia, Ybreast Yenlargement, Yacne, Yand Yedema.
8. A Ynurse Yis Yreinforcing Yteaching Ywith Yan Yolder Yadult Yclient Ywho Yhas Ysevere YL-sided YHF. YWhich Ystatement Yshould
Ythe Ynurse Ymake?
ANS: YRest Yfor Y15 Yminutes Ybetween Yactivities.
- The Ynurse Yshould Yinstruct Yto Yincrease Yhis Yactivity Ygradually Y& Yto Yrest Yfor Ya Yperiod Yof Y15 Ymin Yif Yhe Ybecomes Ytired.
Clients Ywho Yhave YHF Yshould Ybalance Yactivity Yc Yrest Yto Yreduce Ycardiac Yworkload.
9. A Ynurse Yin Ya YLTC Yfacility Yis Ydocumenting Ythe Ycare Yof Yan Yolder Yadult Yclient. YWhich Yinformation Yshould Ybe
Yincluded Yin Yweekly Ynursing Ycare Ysummary?
ANS: YHydration YStatus
- Older Yadult Yclient Yare Yat Yrisk Yfor Ydehydration. YTherefore, Ythe Ynurse Yshould Ybe Yvigilant Yabout Ymonitoring
Ythe Y Yclient’s Yhydration Ystatus Y& Yinclude Ythis Yinformation Yin Ythe Yweekly Ynursing Ycare Ysummary.
, 10. A Ynurse Yis Ycaring Yfor Ya Yclient Ywho Yhas Ya Yhead Yinjury. YUsing Ythe YGlasgow YComa YScale Yto Ycollect Ydata, Ythe
Ynurse Yshould Yobtain Ywhich Yinformation?
ANS: YMotor YResponse
- The Ynurse Yshould Ycollect Ydata Yabout Ythe Yclient’s Ymotor Yresponse Y& Yassign Ythe Yresponse Ya Yscore Yof Y1-6,
Yaccording Y Yto Ythe YGlasgow YComa YScale.
11. A Yhome Yhealth Ynurse Yis Yreinforcing Yteaching Ywith Ya Yclient Yabout Ythe Yuse Yof Yelastic Ystockings Yto Ydecrease
Yperipheral Yedema. YWhich Yinstruction Yshould Ythe Ynurse Yinclude?
ANS: YApply Ythe Ystocking Yin Ythe Ymorning.
- The Ynurse Yshould Yinstruct Ythe Yclient Yto Yapply Ythe Yelastic Ystocking Yin Ythe Ymorning Yand Yremove Ythem Yat Ythe Yend
Yof Y Ythe Yday Ybefore Ybedtime.
12. A Ynurse Yis Yobtaining Yhealth Yhx Yfrom Ya Yclient Ywho Yis Yscheduled Yto Yundergo Ycardiac Ycatheterization Yin Y2 Ydays.
YWhich Yquestions Yis Ythe Ypriority Yfor Ythe Ynurse Yto Yask?
ANS: Y“Do Yyou Yknow Yif Yyou’re Yallergic Yto Yiodine?”
- The Ygreatest Yrisk Yto Ythe Yclient Yis Yan Yallergic Yreaction Yto Ythe Ycontrast Yagent, Ywhich Ycontains Yiodine.
13. A Ynurse Yis Yplanning Yto Yadminister Ynystatin Yoral Ysuspension Yto Ya Yclient Ywho Yhas Yoral Ycandidiasis. YWhich
Yinstructions Yshould Ythe Ynurse Ygive?
ANS: Y“Hold Ythe Ymedication Yin Yyour Ymouth Yfor Yseveral Yminutes Yprior Yto Yswallowing”
- The Yclient Yshould Yswish Y& Yhold Ythe Yliquid Yin Ythe Ymouth Yfor Yat Yleast Y2 Ymin Yto Yfacilitate Ycontact Yof Ythe
Ymedication Y Ywith Ythe Yorganism. YThe Yclient Yshould Ythen Yswallow Yor Yspit Yout Ythe Ymedication.
14. A Ynurse Yis Ypreparing Yto Ycare Yfor Ythe Yassigned Yclients Yon Yher Yupcoming Yshift. YWhich Ytime Ymanagement
Ystrategies Yshould Ythe Ynurse Yplan Yto Yuse?
ANS: YPrepare Ya Ypriority Ylist Yof Yclient Yneeds Yfor Ythe Yshift.
- The Ynurse Yshould Yprepare Ya Yclient Ypriority-to-do Ylist, Ywhich Ycould Yinclude Yadministering Ytime-critical Ymedications.
This Ywill Yallow Ythe Ynurse Yto Ydetermine Ywhich Yclients Yshould Yreceive Ycare Yfirst.
15. After Ywitnessing Ythe Yconsent, Ywhat Yaction Yshould Ythe Ynurse Ytake
Ynext? YANS: YAsk Yclient Ywhat Yhe Yunderstands Yabout Ythe Yprocedure.
16. Which Ytask Yshould Ythe Ynurse Yassign Yto Yan YAP Yfor Ya Ypt Y2 Ydays Ypost-op Yff YTotal Yknee
Yarthroplasty? YANS: YReapply Yantiembolitic Ystockings Yto Ythe Yclient Yff Ya Yshower.
17. A Ynurse Yis Yreinforcing Yteaching Ywith Ya Yclient Ywho Yis Yreceiving Yradiation Ytherapy Yfor Ycancer Yof Ythe Ylarynx.
YWhich Ystatement Ymade Yby Ythe Yclient Yindicates Yunderstanding Yof Ythe Yteaching?
ANS: Y“I Ywill Ywear Ya Ysoft Yscarf Yaround Ymy Yneck Ywhen YI Yam Youtside”
- Wash Yit Ywith Yplain Ywater Ywithout Ysoap. YNO Yheat Ysource Ytherapy. YOnly Yuse Yelectric Yrazor Yif Ynecessary, Yfor Yshaving.
18. A Ynurse Yis Yusing YFLACC Yscale Yto Ydetermine Ythe Ylevel Yof Ypain Yfor Yan Y11-months-old Yinfant Ywho Ysis Yport-op.
YWhich Yfactor Yshould Ythe Ynurse Yconsider Ywhen Yusing Ythis Ypain Yscale?
ANS: YLevel YOf YActivity
- The Ynurse Yshould Yconsider Ythe Yinfants Ylevel Yof Yactivity Ywhen Yusing YFLACC Ypain Yscale. YThe YFLACC Yis Ydetermined Yby
Y
