ATI PN COMPREHENSIVE EXIT EXAM_SOLVED_100%

1. The nurse is preparing to assist the patient in using the incentive spirometer.
Which nursing intervention should the nurse provide first?
a. Perform hand hygiene.
b. Explain use of the mouthpiece.
c. Instruct the patient to inhale slowly.
d. Place in the reverse Trendelenburg position.
ANS: A
Performing hand hygiene reduces microorganisms and should be performed first.
Placing the patient in the correct position such as high Fowler’s for the typical
postoperative patient or reverse Trendelenburg for the bariatric patient would be
the next step in the process. Demonstration of use of the mouthpiece followed by
the instruction to inhale slowly would be the last step in this scenario.
2. The nurse and the nursing assistive personnel (NAP) are caring for a group of
postoperative patients who need turning, coughing, deep breathing, incentive
spirometer, and leg exercises. Which task will the nurse assign to the NAP?
a. Teach postoperative exercises.
b. Do nothing associated with postoperative exercises.
c. Document in the medical record when exercises are completed.
d. Inform the nurse if the patient is unwilling to perform exercises.
ANS: D
The nurse can delegate to the NAP to encourage patients to practice postoperative
exercises regularly after instruction and to inform the nurse if the patient is
unwilling to perform these exercises. The skills of
demonstrating and teaching postoperative exercises and documenting are not
within the scope of practice for the nursing assistant. Doing nothing is not
appropriate.
3. The nurse is providing preoperative teaching for the ambulatory surgery
patient who will be having a cyst removed from the right arm. Which will be the
best explanation for diet progression after surgery?