Priority-Setting Frameworks, Infection Control and Isolation, Health Care Delivery, ATI - Nursing Foundations Test
A nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as the priority for care?
A client who received digoxin and has a heart rate of 48/min
A nurse is teaching a client about the Affordable Care Act (ACA). Which of the following information should the nurse include?
A focus of the ACA is disease prevention.
A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's Hierarchy of Needs. (Move the levels into the box on the right, placing them in the order of priority. Use all the levels.)
Physiological Safety Love/Belonging Esteem Self-actualization
A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?
Reservoir
A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable use of social media?
Reviewing the use of a fitness application with a client
A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's Hierarchy of Needs?
Self-esteem
A nurse is teaching a client about hospice care. Which of the following statements by the client indicates an understanding of the teaching?
"I understand that services provided will include just what is needed to keep me comfortable."
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?
"Remove nail polish on your fingernails if it is chipped."
A nurse is providing education on priority setting frameworks to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?
"This framework assigns the highest priority to the situation that poses a threat to the client's physical well-being."
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?
Soap and water
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection?
Susceptible host
A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?
Swab the back of the client's pharyngeal wall.
A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment?
ABCDE
A nurse in a provider's office is speaking with a client who needs a refill for a prescription that has expired. The nurse should identify that which of the following team members can assist the client with the refill? (Select all that apply.)
APRN PA Physician
A nurse is teaching a newly licensed nurse about The Joint Commission (TJC). Which of the following information should the nurse include?
TJC ensures organizations remain up-to-date with state guidelines.
A nurse is discussing social determinants of health with a newly licensed nurse. The nurse should include that which of the following factors contribute to the neighborhood and built environment determinant category? (Select all that apply.)
Access to foods that support healthy eating patterns. Crime and violence Environmental conditions
A nurse in a clinic is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Which of the following care facilities should the nurse anticipate the client be admitted to?
Acute care hospital
A nurse is reviewing the contributions of various nursing organizations that provide support in caring for clients. The nurse should identify that which of the following agencies provides The Nursing Scope and Standards of Practice?
The American Nurses Association (ANA)
A nurse at a community health center is providing an in-service for a group of residents about the Healthy People program. Which of the following information should the nurse include? (Select all that apply.)
Initiatives to reduce health care disparities. Activities to improve social determinants of health. Improving access to health care.
A newly licensed nurse is reviewing Benner's Novice to Expert Model for nursing competence. At which of the following stages does the nurse first develop the ability to prioritize tasks by drawing on experience?
Competent
A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?
Contact
A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?
Convalescence
A nurse is reviewing a report by the Institute of Medicine (IOM). Which of the following competencies should the nurse identify health care professionals need in order to reduce errors? (Select all that apply.)
Cooperation Communication Coordination
A nurse is performing the role of case manager for a client. Which of the following actions demonstrates this nursing role?
Coordinating and overseeing the care the client is receiving
A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first?
Cover the IV site with an elastic bandage.
A nurse is caring for a client who tells the nurse they want to quit smoking. The nurse provides the client with information about smoking cessation and other ways to improve their health. Which of the following nursing roles is the nurse demonstrating? (Select all that apply.)
Health Promoter Nurse educator
A nurse is completing the Minimum Data Set (MDS) assessment for a resident in a skilled-nursing facility. Which of the following information should the nurse include in the assessment? (Select all that apply.)
Input from team members of the client's Interdisciplinary team. The client's cognitive status. Each physical therapy visit. The client's need for assistance with ADLs.
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?
Airborne
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?
Apply chlorhexidine and ethanol to the hands.
A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?
Bacteria
A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's airway and breathing status. Which of the following assessments should the nurse perform next?
Blood pressure
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?
C-reactive protein
A nurse working in an acute care facility is caring for a client who has a total brain injury and is receiving mechanical ventilation. Which of the following facilities should the nurse anticipate the client to be transferred to for further treatment?
LTCH
A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?
A client who is receiving a blood transfusion and reports urticaria
A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first?
A client who has an abdominal wound that is actively bleeding
A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who has audible wheezing during respirations
A nurse has accepted a position at a hospital in the state where they live. The nurse should identify that which of the following regulates the nurse's actions when they begin working?
The state Nurse Practice Act
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?
Try to use alternatives before inserting indwelling urinary catheters.
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Turns off the faucet with a towel
A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care?
Urgent
A nurse is teaching about Medicaid to a client who is concerned about paying for health care. Which of the following statements should the nurse make?
"Your income will determine if you are eligible for Medicaid."
A nurse at a provider's office is reviewing the records of several clients. Which of the following clients should the nurse recommend as the priority for treatment?
A client who reports new chest pain
A nurse is talking with a client who arrived at the clinic over an hour ago and states, "Doesn't anyone care that I am sick? Why do I have to wait so long?" The nurse listens to the client and notifies the provider, relaying the needs of the client. In which of the following roles is the nurse performing?
Advocate
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?
Airborne
A nurse is caring for a client who asks about healthy choices to lose weight. The nurse shares information from Healthy People 2030 to address the client's questions. Which of the following describes the Healthy People initiative?
It is a set of objectives for improving the health of Americans.
A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first?
Perform a physical assessment
A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?
Place the client in a private room.
A nurse is discussing hospice care with a newly licensed nurse. Which of the following should the nurse identify as the goal of hospice care?
Provide care for a client who has less than 6 mos to live.
A nurse is reviewing the contributions made by various nursing organizations that have impacted the nursing profession. The nurse should identify that which of the following are contributions made by The American Nurses Association (ANA)? (Select all that apply.)
Providing a definition of nursing is correct. Lobbying for whistle blower protection is correct. Providing all registered nurses with competency expectations is correct.
A home health nurse is caring for a client who is receiving hospice care. The client's partner reports feeling overwhelmed from caring for the client. Which of the following types of facilities should the nurse recommend?
Respite care
A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include?
The American Nurses Association's The Code of Ethics for Nurses with Interpretive Statements guides nurses through difficult decisions.
A nurse is teaching a class about the Hospital-Acquired Condition Reduction Program (HACRP). Which of the following information should the nurse include?
The HACRP links Medicare payments to health care quality.
A nurse is reviewing the Institute of Medicine (IOM) Future of Nursing report to better understand proposed educational requirements of nurses. Which of the following organizations is responsible for publishing this report?
The National Academy of Medicine
A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority?
The client reports dizziness when standing
A nurse is reviewing the health history of a client during a routine office visit. Which of the following observations by the nurse is an example of the client demonstrating health literacy?
The client states they understand their health care information and treatments,
A nurse is discussing culturally competent care with another nurse. Which of the following statements should the nurse include?
"Use a medical interpreter for a client who does not speak the same language."
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?
Open the first flap on the sterile package away from their body.
A nurse in a provider's office is calling a client's insurance company to obtain permission prior to scheduling a magnetic resonance imaging (MRI) test. Which of the following is the nurse obtaining?
Precertification
A nurse is caring for a client who has Parkinson's disease and needs assistance with ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe?
Dietitian Physical therapist Occupational therapist
A nurse is caring for a client who reports that they have recently lost their job and do not have insurance coverage. Which of the following social determinants of health is challenging for this client?
Economic stability
A nurse educator is planning a presentation for nurses about the opioid epidemic. Which of the following is a strategy promoted by the U.S. Department of Health and Human Services to address this epidemic?
Educate nurses and other health care personnel about naloxone.
A nurse in a provider's office is speaking with a client about a Press Ganey survey. The nurse should inform the client that this survey will be conducted by which of the following methods?
A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?
Prodromal
A nurse is teaching a newly licensed nurse about Medicare reimbursement. Which of the following should the nurse include in the teaching?
Reimbursement amounts will be adjusted for clients who contract HACs.
A nursing student expresses a desire to become more involved with the nursing profession on a national level. Which of the following organizations should the student join?
The National Student Nurses' Association
A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?
Droplet
A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (Select all that apply.)
Observe the client's lower extremities for indications of deep vein thrombosis. Measure the client's temperature. Check the client for bruising.
A nurse is explaining to a newly licensed nurse that caring for clients involves lifelong learning by the nurse. The nurse should include which of the following as examples of learning opportunities for nurses? (Select all that apply)
Online continuing education journals Nursing skill refresher Continuing education presentation Participating in healthcare research
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?
Report needlestick injuries to the nursing supervisor.
A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?
Gloves
A community health nurse is teaching a newly licensed nurse about social determinants of health. Which of the following should the newly licensed nurse identify as a physical determinant of health?
Poor air quality
A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?
Droplet
A nurse in a long-term care facility took a picture of a client and posted it on the internet. This action by the nurse is an example of which of the following?
Violating the code of ethics for nurses.
A nurse is planning to admit a client who has respiratory syncytial virus. Which of the following precautions should the nurse plan to implement?
Droplet
A nurse is caring for a client who reports experiencing chills and not feeling well. The nurse informs the client that they will need to have their temperature taken to monitor the manifestations. Which of the following terms describes that the nurse's action is grounded in research?
Evidence-based practice
A nurse is hired to be a case manager in a facility. Which of the following services should the nurse expect to perform?
Facilitate transfer of clients to meet the req'd level of care.
A nurse is reviewing historical nursing data and how it has impacted nursing care. The nurse should identify that which of the following nursing pioneers is credited with first using evidence-based practice in caring for clients?
Florence Nightingale
A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?
Gloves should be removed from the inside out.
A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements?
Report this omission to the charge nurse and the nurse on the next shift.
A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?
After changing a dressing on the client and before documenting findings on a computer
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?
The door to the AIIR should remain closed.
A nurse is teaching a newly licensed nurse about the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) tool. Which of the following information should the nurse include?
The HCAHPS tool is issued to measure client satisfaction with the health care service.
A graduate nurse notes that a hospital with Pathway to Excellence® recognition is hiring staff. Which of the following should the nurse expect from this facility? (Select all that apply.)
The facility has practices in place that lead to a healthy workplace environment. The facility emphasizes shared governance. The facility emphasizes practices that positively affect a nurse's well-being.