ATI Safe Effective Care

A nurse is assisting with the admission of a client who has tuberculosis and a productive cough. Besides standard precautions, which type of precautions should the nurse contribute to the client's plan of care?

Airborne

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

"It is a good idea to use the handrails in the bathroom."

A nurse is reinforcing teaching with a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

"You should advance your weak leg forward to the cane, then move your strong leg"

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (select all that apply)

- Document restraint checks and client status every 2 hr.- Educate the client's family about restraint use.- Implement passive range-of-motion exercises.

A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider?

25 mg/dL

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client ans supporting the client's decisions?

Advocate

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms.

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity?

Assigning tasks to an assistive personnel (AP)

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.)

Broth Grape juice Lemon gelatin

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Bruxism

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Cartoid

A nurse is providing postmortem care. Identify the sequence of steps the nurse should follow.

Certification of death declared by the provider.Organ/tissue donation status verified by the nurse.Medical equipment removed from the client.Body cleansed while adhering to body fluid precautions.Identification tag applied to the body.

A nurse is providing hygiene care for a client who is immobile. Which actions should the nurse take? (select all that apply)

Check for personal items when changing the bed linens Keep the bath water temperature between 43.3 C (110 F) and 46.1 C (115 F) is Shave the client's hair in the direction of the hair growth

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?

Check that the client lifts the walker and then places it down in front of her.

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Check the stockings for wrinkles

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

Earlobe

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his days in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion

A nurse is assessing a client who has diabetes mellitus and is experiencing foot pain. Which of the following are signs and symptoms of an infection? (Select all that apply).

Increased neutrophils Localized edema

A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of pyschosocial development?

Integrity vs. despair

A nurse needs to lift a box in a supply room. which of the following actions should the nurse take to prevent an injury due to lifting?

Keep the box close to his body as he lifts.

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the spine. The nurse should expect the provider to document which of the following disorders?

Kyphosis

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness would with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Laceration

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair.

A nurse is assisting a client during ambulation when the client begins to fal. Which ofthe following actions should the nurse take?

Lower the client to the floor

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of PPE should the nurse remove first?

Mask

A nurse is caring for a client who requires droplet precautions Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Mask

A nurse is teaching a client about crutch walking using the three point gait. Which of the following statements by the nurse should be included in the teaching?

Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches.

A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship?

Narrative interaction

While assessing a client's temporomandibular joint, the nurse identifies pain, crepitus, and a popping sound. based on these findings, to which of the providers should the nurse request a referral for the client?

Oral surgeon

A nurse is assessing a client who has wrist restrain applied. For which of the following findings should the nurse loosen the restrain?

The client's hand is cool and pale

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?

The client's sociocultural background influences nonverbal communication.

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

The nurse has already considered alternatives to restraints

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Urine output of 175 mL in the past 8 hr

A nurse in community health clinic is caring for a client who has a new diagnosis of plantar warts. The nurse should include which of the following in the teaching plan for his client?

They may be painful with ambulation.

A nurse is providing oral care for a client who is immobile. Which of the follow actions should the nurse take?

Turn the client on his side before starting oral care

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nursing using a friction reduction device.

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Use attentive listening with the client

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Ventricular gallop

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC count

A nurse accidentally sticks her hand with syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Wear clean gloves.

A nurse in a provider's is caring for a client who reports pruitus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders?

contact dermatitis