ATI Fundamentals exam 1 part A

A nurse is assessing an older adult clients risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs?

Pupil clarity Visual fields Visual acuity

A nurse is preparing to administer enoxaparin subcutaneous to a client. Which of the following actions should the nurse take? Administer the meds with the needle at a 45 degree angle Administer the meds into the clients non dominant arm Pull the clients skin laterally or downward prior to administration Massage the injection site after administration

Administer meds with the needle at a 45 degree angle.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the clients room. When the nurse ask if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? I will return Hartley after i document this in your record Most men live a long time with prostate cancer I am available to talk if you should change your mind I will make a referral to a cancer support group for you.

I am available to talk should you change your mind

A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for the client.

Make sure the client wears a mask when outside her room if there is construction in the area.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which the following actions should the nurse take? Assist the client into a prone position Place a sleeve over the top of each leg with the opening at the knee Make sure two fingers can fit under the sleeves Set the ankle pressure at 65 mm Hg

Make sure two fingers can fit under the sleeves

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and report back in 1 hour. Which of the following actions should the nurse take? Document the providers statement in medical records. Complete an incident report. Consult The facilities risk manager Notify the nursing manager

Notify the nurse manager

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? BUN 15mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L

Potassium 5.4 mEq/L

A nurse in an emergency department is caring for a client. Physical examination: Influenza with nausea, vomiting, and diarrhea for the past 3 days. Client is tachycardia, hypotensive, and tachypenic, with weak pulses, dry mucous membranes, poor tugor, and oliguria. Plan: admit for IV fluids Vital signs: 1200: Temp: 101.1F Pulse rate: 126/min RR: 28/min BP: 92/54 mm Hg O2: 93% Nurse notes: 1900: Client is disoriented, confused. Client attempting to to get out of bed without assistance and states, I'm going home. Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to clients family. No answer. 1915: Client remains disoriented. Attempted to pull out IV line. Call was returned by family, they were updates. Med Administration Record -Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr Promethazine 25mg IV bonus every 4-6hr PRN nausea and vomiting Diphenoxylate 5mg PO 4x daily Acetaminophen 625mg PO very 6 hours PRN temperature greater than 101.5F The nurse should first ___ followed by _____

Review medications that might be causing confusion is correct Padding bony prominences under the restraint

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? Use the complete name of the medication magnesium sulfate Delete the space between the numerical dose and the unit of measure Write the letter U when noting the dosage of insulin Use the abbreviation SC when indicating an injection

Use the complete name of the medication magnesium sulfate