ATI Capstone Fundamentals Post-Study Quiz

ATI Capstone Fundamentals Post-Study Quiz
A nurse enters a client's room and finds the client on the floor experiencing a seizure. Which of the following actions should the nurse take? - ANSPosition the client on their side.

The nurse should position the client on their side. This assists the client's airway to remain open and can prevent aspiration if the client has emesis or secretions in their mouth.

A nurse is assessing a client who has enlarged lymph nodes. In which of the following locations should the nurse palpate to locate the postauricular nodes? - ANSOver the mastoid

The nurse should palpate over the mastoid or behind the ear to assess the postauricular nodes. The detection of an enlarged or tender lymph node can indicate the presence of an infection or a malignancy and should be reported to the provider.

A nurse is assessing a client who has multiple sclerosis. Which of the following assessments is the nurse's priority? - ANSAbility to swallow

The greatest risk to the client is aspiration due to dysphagia. Therefore, the nurse's priority assessment is the client's ability to swallow.

A nurse is assisting a client to ambulate to the bathroom when the client begins to fall. Which of the following actions should the nurse take? - ANSPlace one foot in front of the other while spreading the feet apart.

The nurse should place one foot in front of the other while spreading the feet farther apart to widen their own base of support. Then the nurse should lower the client to the floor as smoothly as possible. This will assist with supporting the client's weight and help to prevent injury to the nurse.

A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment is present in the client's room? - ANSAn obturator

The nurse should ensure that a client who has a tracheostomy has an obturator at their bedside. If the tracheostomy is dislodged, an obturator is used to reinsert the outer cannula of the tracheostomy. The nurse should also ensure that a spare tracheostomy of the client's size, as well as a tracheostomy of one size smaller, supplemental humidified air or oxygen, and suction equipment are at the client's bedside to ensure safe client care.

A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates that the nurse should modify the client's plan of care? - ANSReports pain as a 5 on a scale of 0 to 10

A report of pain as 5 on a scale of 0 to 10 indicates the client is experiencing moderate pain. The nurse should contact the provider to obtain a prescription for pain management interventions and should update the client's plan of care.

A nurse is caring for an older adult client who is postoperative following abdominal surgery. Which of the following age-related changes can result in delayed wound healing? - ANSDecreased sebum production

The nurse should identify that older adult clients experience a decrease in sebum production, which causes the skin to become dry and can cause an increase in cracking. This can result in delayed wound healing.

A nurse is creating a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan? - ANSHave the client demonstrate the use of the call light.