CCC 1 ATI Fundamentals PN Funds Practice Set 2 of 4
While auscultation a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? * A cardiac murmur * A third heart sound (S3) * An expected heart sound * A fourth heart sound (S4)
A cardiac murmur - Cardiac murmurs are relatively loud, turbulent sounds the nurse can hear between the usual, expected heart sounds. They create a whooshing or a switching sound
A nurse is caring for a client who has schizophrenia. The client asks about medications, their effects, and when the voices will stop that speaks to him frequently. The nurse responds by asking the client why he needs to know this. This is an example of which non therapeutic communication techniques? *Changing the subject * Asking for explanation * Defensive response * Arguing
Asking for explanation - The use of a "why" question requires that the client provide an explanation that he may not have. A better response would be to give a reasonable answer to the question and clarify any additional concerns of the client.
A nurse is caring for a client within the intimate zone of the cliet''s personal space. Which of the following activities by the nurse occurs in this space? (SATA) * Auscultating heart sounds * Reinforcing teaching about a medication * Discussing intake and output * Talking with the client's partner
Auscultating heart sounds - This occurs within 0 to 18 inches which is within the intimate zone of the client's personal space Changing a dressing - This occurs within 0 to 18 inches which is within the intimate zone of the client's personal space ****************************************************** Discussing intake and output is INCORRECT. This can occur within either the personal (18 to 4 feet) or social zone (4 to 12 feet) Talking with the client's partner is INCORRECT. This occurs within either the social zone (4 to 12 feet)
A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who is Orthodox Jewish. On the try is a roast beef dinner with nonfat milk. Which of the following is an appropriate nursing action? * Allow the AP to deliver the food tray to the client * Call the dietary department and ask for a kosher tray * Replace the nonfat milk with apple juice * Explain to the client that he needs the protein in the milk and beef
Call the dietary department and ask for a kosher tray - This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who are Orthodox Jewish do not eat meat and dairy together.
A nurse is preparing to reinforce teaching for a client who has just found out that she has type 2 diabetes mellitus. What is the nurse's priority in contributing to this plan? * Establish short-term, realistic goals for the client * Give her access to a video about diabetes * Determine what the client knows about managing her diabetes * Evaluate the effectiveness of the client's admission teaching plan
Determine what the client knows about managing her diabetes - The first action the nurse should take using the nursing process is to assess or collect data from the client. the nurse should find out what the client knows before proceeding with plan.
A nurse is having difficulty caring for a client due to interpersonal variables affecting the communication process. Which of the following is an interpersonal variable? (SATA) * Education * Feedback * Gender * Perception * Time
Education is correct. The educational background of the client is an interpersonal variable that affects the communication process. Gender is correct. Gender is an interpersonal variable that affects the communication process. Perception is correct. Perception provides a uniquely personal view to an individual's experience and is an interpersonal variable that affects communication. ******************************** Feedback is INCORRECT. Feedback is the message that the sender returns in the communication process. It is not an interpersonal variable. Time is INCORRECT. Time is a critical element of the communication process. It is not an interpersonal variable.
A nurse is caring for a client and is in the nurse-client helping relationship. Which of the following communication techniques should the nurse use in this phase? * Elicit information from the client * Encourage the client to use self-exploration * Review the client's progress toward personal objectives * Talk with others who have information about the client
Elicit information from the client - Obtaining information from the client is an appropriate communication technique in the orientation phase
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from the client, the nurse should expect to find which of the following early indications of hypoxia? * Bradypnea * Hypertension * Cyanosis * Peripheral edema
Hypertension - During the early stages of hypoxia, blood pressure is usually elevated unless shock is the cause of the hypoxia. in the late stages of hypoxia, client's are likely to develop hypotension.
A nurse is reinforcing teaching to a client about carbon monoxide poisoning. Which of the following statement by the client indicates a need for further teaching? * A high concentration of carbon monoxide can cause death * I can detect the presence of carbon monoxide by a metallic odor * I can purchase a carbon monoxide detector for my home * I should inspect my carbon monoxide detector annually
I can detect the presence of carbon monoxide by a metallic odor - This os not an appropriate statement by the client and indicates a need for further teaching. Carbon monoxide is odorless
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? * Reposition the client every 3 hr * Massage bony prominences to promote circulation * Provide the client with a diet high in protein * Apply cornstarch to keep the skin dry
Provide the client with a diet high in protein - Inadequate protein, iron, vitamins, and calories increase the risk for skin breakdown
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which health care professional is responsible for obtaining information consent from the client for the procedure? * Nurse * Anesthesiologist * Surgeon * Surgical suite nurse
Surgeon - The person who will perform the treatment or procedure is responsible for obtaining information consent from client. The surgeon who is performing the hip repair would be responsible for obtaining for obtaining informed consent.
A nurse is preparing an inservice for a group of newly licensed nurses about organ donation. Which of the following information should the nurse include? * The nurse caring for the client at time of death should request organ donation * Donation costs are the responsibility of the donors family and estate * The nurse may serve as a witness to a consent for organ donation * Clients who meet age requirements may donate whichever organs they choose
The nurse may serve as a witness to a consent for organ donation - Nurses may witness families signing consents for organ donation after a specially trained professional request consent
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? * One nurse lifting as the client pushes with his feet * Two nurses using a friction reduction device * One nurse lifting the client's legs as the client uses a trapeze bar * Two nurses lifting the client under the shoulders
Two nurses using a friction reduction reduction device - Two nurses, using a friction-reusing device is the appropriate method to move the client up in bed
A nurse is preparing to administer a cleansing enema for a client who has constipation. Which of the following is an appropriate action by the nurse? * Keep the container of solution at a level to maintain client comfort. * Hold the container of solution 12 inches above the anus * Hold the container of solution level with the upper hip * Slowly lower the container 24 inches below the anus
Hold the container of solution 12 inches above the anus - The nurse holding the container of solution 12 to 18 inches above the anus is correct to allow a greater force of fluid flowing to properly cleanse the colon.
A nurse is reinforcing discharge teaching to c client who is prescribed home oxygen therapy. Which of the following statement by the client indicates a need for further teaching? * I will ensure that visitors smoke outside * I should see a frosty buildup on the tank when I refill my portable oxygen * I will be able to tell how oxygen is being delivered by looking at the flowmeter * I should call my doctor if I experience a decreased ability to concentrate
I should see a frosty buildup on the tank when I refill my portable oxygen A snow-like precipitate indicates a leakage of oxygen; therefore, this statement by the client indicates a need for further teaching
A nurse is reinforcing teaching to a group of assistive personal (AP) about caring for clients with restraints. Which of the following statements by one of the APs indicates an understanding of the teaching? * I will tie restraints in double knots * I will tie a restraints to the moving parts of the bed frame * I will ensure that restraints fit tightly against the client * I will put four side rails up if a client is confused
I will tie a restraint to the moving part of the bed frame - This statement by one of the AP's indicates an understanding of the teaching. Restraints should be tied to the moving part of the bed frame
A nurse is caring for a client who is being admitted from a long-term care facility. When would the use of a closed-ended question by the nurse be appropriate? * When determining if the client is eating a well-balanced diet * In asking if the client took his medications this morning * When asking the client how he completes his ADLs * In asking the client about his receptiveness to the transfer
In asking if the client took his medication this morning - A "yes" or "no" response is appropriate when asking if a client took his morning medications
A nurse is planning to collect data on a client's abdomen who reports "stomach pain". Which of the following actions should the nurse do first? * Auscultate * Percuss * Inspect * Palpate
Inspect - The nurse should inspect the abdomen for external abnormal conditions first
After signing an informed consent form, a client states, "I have changed my mind and do not want to have the procedure done."Which of the following are appropriate nursing responses? * Remind the client that a signed informed consent form is a legally binding document * Notify the surgeon that the client wishes to withdraw informed consent for the procedure * Inform the surgical team to cancel the client's surgery * Proceed with preparation of the patient for surgical procedure
Notify the surgeon that the client wishes to withdraw informed consent for the procedure - The client has the right to withdraw informed consent; therefore, the surgeon who is the one to obtain the information consent should be notified of the request.
A goal for a client who has difficulty with the physical aspects of feeding herself due to rheumatoid arthritis is to use adaptive devices to enhance her capabilities. The nurse caring for the client for the client should initiate a referral with which of the following members of the collaborative health care team? * Occupational therapist * Social worker * Registered dietitian * Speech pathologist
Occupational therapist - An occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities. An occupational therapist could assist someone with a self-care deficit for feeding through the use of adaptive devices.
A nurse in a community clinic is assessing a client who reports uncontrolled vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (SATA) * Poor skin turgor * Bradycardia * Hypotension * Pale yellow urine * Furrowed tongue
Poor skin turgor - Uncontrolled vomiting and diarrhea cause dehydration, which manifests as skin turgor that lacks elasticity Hypotension - Uncontrolled vomiting and diarrhea cause dehydration, which manifests as hypotension, particularly postural hypotension. Furrowed tongue - Uncontrolled vomiting and diarrhea cause dehydration, which manifests as longitudinal tongue furrows. **************************************************** Bradycardia is INCORRECT uncontrolled vomiting and diarrhea cause dehydration, which manifests as tachycardia. Pale yellow urine is INCORRECT uncontrolled vomiting and diarrhea cause dehydration, which manifests as dark yellow, concentrated urine.
A nurse is reinforcing teaching with a family member on how to position a client when administering enteral feeding at home. Which of the following family member statements indicate understanding of the correct position? * I will allow the position of comfort during the feeding * Position the head of the bed 40 degrees during the feeding * Elevate the head of the bed 10 degrees during feeding * Turn on the left-side lying position during the feeding
Position the head of the bed 40 degrees during feeding - The head of the bed should be elevated 30 to 40 degrees to avoid aspiration, which indicates the family member understands the correct position during enteral feedings.
A nurse manager is assigning care responsibilities for the upcoming shift. A client is awaiting transfer back to the unit from the PACU following hip arthroplasty. To which staff member should the nurse assign to this client? * Charge nurse * LPN * RN * Assistive personnel (AP)
RN - A client returning from a surgical procedure requires assessment and establishment of a plan care. RNs are responsible for client assessment, establishment of an individualized plan of care, and identification of client outcomes. An RN is the appropriate choice.
A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" The nurse responds, :It must be very frustrating to encounter this kind of attitude. "The nurse is using which of the following therapeutic communication techniques? * Clarifying * Reflection * Focusing * Paraphrasing
Reflection - Reflection involves responding to the content and emotional components of a message by restating the client's feelings.
A nurse is caring for an older client who has a fractured hip and will require rehabilitative care. Which of the following statements is appropriate? * Rehabilitation began with the client's admission to the hospital * The focus of rehabilitative care is the client's physical injuries * The client will require long-term rehabilitation services * The client will require inpatient rehabilitation services
Rehabilitation - Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the best possible level of functioning. The process of rehabilitation begins with the client's acute care hospital admission.
A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (SATA) * Repeat the order back to the prescriber * Question any part of the prescription that is unclear or inappropriate * Transcribe the prescription into the client's medical record * Obtain the prescriber's signature within 8 hr * Implement a voice mail prescription if the nurse can hear and understand it well
Repeat the order back to the prescriber - The nurse should read it back and have the prescriber confirm verbally that it is correct. Question any part of the prescription that is unclear or inappropriate is correct. - This is essential for any prescription, verbal or written. Transcribe the prescription into the client's medical record is correct. - This is the usual procedure after accepting a telephone prescription. *********************************** Obtain the prescriber's signature within 8 hr is INCORRECT. Although the policy may vary with the facility, the usual rule is to obtain the prescriber's signature within 24 hr Implement a voice mail prescription if you can hear and understand it well is INCORRECT. If a provider leaves a voice mail prescription, the nurse should call back the provider and take the prescription verbally over the telephone.
When planning a home discharge for a client who has quadriplegia, the nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses is appropriate? * Respite care allows the primary caregiver time away from day-to-day care responsibilities * Respite care provides holistic support and care for a client who is terminally ill * Respite care helps relieve or reduce the intensity of uncomfortable symptoms * Respite care is a continuation of psychological support after a family member dies
Respite care allows the primary caregiver time away from day- to- day care responsibilities - A client who has quadriplegia requires support for many activities of daily living daily living. Primary caregivers need time to meet their own personal needs as well. Respite care allows time away from their day-to-day care responsibilities for the client.
A home health nurse is conducting a home safety risk appraisal for an older adult client. Which of the following findings indicates a safety risk for the client? * The home includes a bath tub with rails * Space heaters are present to ensure adequate heating * Electric cords are behind the furniture * Throw rugs are used in the home * There is a seat in the shower stall
Space heaters are present to ensure adequate heating is correct. - Space heaters create a risk for fire, which is a safety risk for the client. This finding should be addressed further. Throw rugs are used in the home is correct. - throw rugs create a rick for falls, which is a safety risk for the client. This finding should be addressed future. ******************************************* The home includes a bath tub with rails is INCORRECT. A bathtub with rails is appropriate, and does not indicate a safety risk for the client. Electric cords are behind the furniture is INCORRECT. Electric cords behind the furniture are appropriate, and does not indicate a safety risk for the client. There is a seat located in the shower stall is INCORRECT. A seat located in the shower stall is appropriate, and does not indicate a safety risk for the client.
A nurse is caring a client and using active listening skills. Which of the following interventions would the nurse use? * Sit side-by-side with the client * Have a pen and paper * Use intermittent eye contact * Learn back in the chair
Use intermittent eye contact - Intermittent eye contact is established and maintained during active listening
A nurse is auscultation the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following? * Crackles * Rhonchi * Wheezes * Stridor
Wheezes - Wheezes are continous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the sirway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.
