Fundamentals ATI practice A

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

wear a gown when caring for the client - The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

withhold the blood transfusion - The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

the client identifies the location of a fire extinguisher - The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.

A nurse is caring for a client who is postoperative following abdominal surgery.

urinary output reported pain level vital signs

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

107 mL/hr

A nurse in a provider's clinic is caring for a client who has heart failure.

I am limiting my sodium intake to 2 grams daily I am eating fewer potato chips and more fruit for snacks I know to call my doctor if I gain 3 pounds or more in 2 days

A nurse is caring for a client who has a new diagnosis of seizure disorder.

The nurse should first address the client's physical safety followed by the client's positioning.

A nurse in an emergency department is caring for a client.

The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

ambulating a client who is postoperative - Ambulating a client is within range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate - Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease in heart rate - Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse in a provider's clinic is caring for a client who has diarrhea.

eat probiotic foods, such as yogurt avoid alcohol while experiencing diarrhea avoid caffeine while experiencing diarrhea follow a low fiber diet

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficle infection. Which of the following information should the nurse include in the teaching?

have family members wear a gown and gloves when visiting - Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficle spores. Staff must also wear gown and gloves.

A nurse enters a client's room and finds them of the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

"Client found lying on floor." - The nurse should include information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgements about motives or cause.

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning." - The client's statement indicates a readiness to learn because they are verbalizing the best time for them to learn.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system." - Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is caring for a client who requires a 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00am and have saved all urine since." - For a 24hr urine collection, the client should discard the first voiding and save all subsequent voiding.

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

"I want you to tell me about measures available to keep me comfortable." - This statement would indicate that the client has accepted that their diagnosis is terminal and is focusing on the goals of palliative care, which are comfort and manifestation control.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?" - Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

"It might help me to listen to music while I'm lying in bed." - Listening to music is an effective nonpharmacological intervention for the management of mild pain.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

"Maintain a consistent time to wake up each day." - The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A middle adult client tells the nurse, "I fell so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people." - According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

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." - The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them." - With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

"Would you like it if we discussed the transfer with your family member?" - This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old." - The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body

A nurse is caring for a client who has a sodium level of 125 mEq/L (136 to 145 mEq/L). Which of the following findings should the nurse expect?

abdominal cramping - This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

administer pain medication 45 min before changing the client's dressing - The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

allow the adolescent to make decisions regarding their daily routine - The nurse should allow the adolescent to make decisions regarding their daily routine in order to give them a sense of control.

A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

an x-ray shows the end of the tube above the pylorus - An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?

assist the client to an upright position - According to evidence-based practice the nurse should assist the client to an upright position. This assists with chest expansion and increases the effectiveness of the existing supplemental oxygen. The nurse should elevate the head of the client's bed to the semi-Fowler's or high-Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (select all that apply)

assist the client with a partial bed bath measure the client's BP after the nurse administers an antihypertensive medication use a communication board to ask what the client wants for lunch

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

bladder scan shows 525 mL of urine - A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A nurse in the emergency department is caring for a client.

cachectic, with flaccid muscle tone skin dry and scaly with bruises on extremities pulse rat 118/min abdomen distended BMI 17

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

compare the client's home medications with the provider's prescriptions - The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

contact precautions - Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers wear a gown and gloves during direct contact with this client.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

distended neck veins - Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?

droplet - Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process - Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm - The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

evacuate the client - According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

have the client use a trapeze bar when changing position - By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure injury development.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

hydrocolloid - Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?

instruct the family to refrain from pushing the button for the client while the client is asleep - The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

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

make sure the client wears a mask when outside their room if there is construction in the area - An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

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 client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

notify the nurse manager - The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

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 make?

pad the client's wrist before applying the restraints - The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply)

place the client in a room with negative-pressure airflow - The nurse should place the client in a room with negative-pressure airflow to meet the requirements or airborne precautions wear gloves when assisting the client with oral care - The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth use antimicrobial sanitizer for hand hygiene - The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also was their hands with soap and water when their hands are visibly soiled.

A nurse is admitting a client.

place the client on droplet isolation precautions apply oxygen at 2L/min via nasal cannula request a prescription for an antipyretic medication remain 1 m from the client

A nurse is caring for a client in a medical-surgical unit.

plan to administer analgesic prior to planned activities assist the client to dangle their legs at the bedside prior to standing delegate the application of sequential compression devices to assistive personnel

A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider?

potassium 5.8 mEq/L (3.5 to 5 mEq/L) - When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

rapid heart rate - Tachycardia is manifestation of fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

role overload - The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

stand close to the cabinet when lifting it - This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

subtract the amount of irrigant used from the client's urine output - The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

tell the client to keep the head of the bed elevated at least 30 - The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30 to prevent reflux of the formula into the esophagus.

A nurse is caring for a client who has a pressure injury.

temperature WBC count prealbumin pain level odor of wound

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

wrap blankets around all four sides of the bed - The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.

A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

wrap monitoring cords with stockinette and tape them in place - Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as a stockinette, and using nonlatex tape to secure them.