Nutrition ATI Test

Correct Answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

Correct Answer: D

Rationale: Selective inattention is a defense mechanism seen in panic-level anxiety. In panic anxiety, individuals may experience selective inattention, where they focus only on specific aspects and ignore others. Mild anxiety does not typically involve selective inattention as individuals can still function effectively. Moderate and severe anxiety may impair attention, but selective inattention is more characteristic of panic-level anxiety.

Correct Answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

Correct Answer: A

Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.

Correct Answer: B

Rationale: The correct answer is B. BCG vaccine can be given to a child with Hepatitis B, as there is no contraindication for this. Choice A, C, and D all present contraindications for administering immunizations. Choice A is incorrect because giving BCG vaccines to a child with AIDS is a contraindication. Choice C is incorrect as convulsions after the first DPT dose indicate a contraindication to subsequent doses. Choice D is incorrect because active convulsions or other neurological diseases are contraindications to receiving the DPT vaccine.