PN 2 NUR 2571 / NUR2571 Basic Care and Comfort - ATI Exam
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PN 2 NUR 2571 / NUR2571
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PN 2 NUR 2571 / NUR2571
PN 2 NUR 2571 / NUR2571 Basic Care and Comfort - ATI Exam
92% Accurate
1. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which statement to the nurse indicates a need for further teaching?
a. I only need to catheterize myself twice a day
b. ...
pn 2 nur 2571 nur2571 basic care and comfort ati exam
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PN 2 NUR 2571 / NUR2571 Basic Care
and Comfort - ATI Exam
92% Accurate
1. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist
down. Which statement to the nurse indicates a need for further teaching?
a. I only need to catheterize myself twice a day
b. I carry a water bottle with me because I drink a lot of water
c. I use a suppository every night to have a bowel movement
d. I do wheelchair exercises while watching TV
2. A nurse is providing hygiene care for a client who is immobile. Which actions should the
nurse take? (select all that apply)
a. Check for personal items when changing linens
b. Place clean gown on strongest arm first
c. Keep bath water temp between 110-115
degF d. Shave hair in direction of growth
e. Wash extremities from proximal to distal
3. A nurse is caring for a client who has impaired mobility. Which of the following support
devices should the nurse plan to use to prevent the client from developing plantar flexion
contractures?
a. Trochanter roll
b. Sheepskin heel pad
c. Abduction pillow
d. Footboard (YES)
4. A nurse is assessing a client who has narcolepsy. Which of the following findings should
the nurse expect? (Select all that apply).
A. A lack of rapid eye movement (REM)
sleep B. Sudden attacks of sleep (yes)
C. Hallucinations at the onset of sleep (YES)
D. Sleep apnea
E. The urge to move the legs when trying to sleep
5. A nurse is administering a cold therapy application to a client. Which of the following
manifestations should the nurse identify as an indication for discontinuing the
application due to a systemic response?
A. Hypotension
B. Numbness
C. Shivering (yes)
D. Reduced blood viscosity
, 6. A nurse is helping an older adult client ambulate in the hallway for the first time since
admission. The client has brought her standard walker from home. To ensure proper use
of the walker and the safety of the client, which of the following actions should the nurse
take?
A. Check that the client lifts the walker and then places it down in front of her. (YES)
B. Walk in front of the client to guide her in moving the walker
C. Have the client move one leg forward with the walker
D. Make sure that the upper bar of the walker is level with the client's waist
7. A client with a decreased LOC is receiving continuous enteral feedings via a gastrostomy
tube due to an inability to swallow. Which is a priority action by the nurse?
a. Observe respiratory
status b. Elevate HOB 30-
45deg
c. Monitor I&O q8h
d. Check residual volume q4-6h
8. A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions should the nurse take first?
A. Determine if the client can bear weight.
B. Place a transfer belt on the client
C. Position the bed at an appropriate height
D. Assist the client to a seated position
9. a nurse is caring for a client who is receiving enteral feedings through an NG tube?
Before administering a feeding the nurse should measure the gastric residual for which of
the following purposes?
A. To confirm the placement of the NG tube
B. To remove gastric acid that might cause dyspepsia
C. To determine the clients electrolyte balance
D. To identify delayed gastric emptying
10. Which strategies should the nurse teach to minimize back strain and avoid repeated
episodes of low back pain? (AVOID PROLONGED SITTING, TRY PADDED
SHOES, NO TO THE SIDE LYING POSITION)
a. Avoid prolonged sitting
b. Apply heat 10min/hr
c. Sleep side-lying with flexed knees
d. Sleep on a soft mattress
e. Try padded shoe
insoles
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