ATI Virtual Fundamentals alternate item format quiz

A nurse is assisting a client with an advance directive. Which of the following nursing responsibilities should be included regarding advance directives? Select all that apply. a. Inform all members of the client's family of the client's wishes. b. Ensure that each family member receives a copy of the advance directive. c. Provide written information to the client about advance directives. d. Document the client's advance directive in the medical chart. e. Confirm that the advance directive is current.

: Confirm that the advance directive is current., Document the client's advance directive in the medical chart., Provide written information to the client about advance directives. The nursing responsibility regarding advance directives is to ensure that the advance directive is current and reflective of the client's current decisions.

A nurse is managing client care. Which of the following should be implemented when prioritizing care? Select all that apply. a. Respond to needs as soon as they arise. b. Postpone items that do not have immediate deadlines. c. Prepare a written list. d. Take on a task when inspired. e. Avoid delegation of difficult tasks.

: Prepare a written list., Postpone items that do not have immediate deadlines. Preparing a written list is a function considered in prioritizing client care. Items that are marked as to do later reflect trivial problems or those that do not have immediate deadlines; thus, they may be postponed when prioritizing care.

An 87-year-old client has been admitted repeatedly to the acute care setting for pneumonia. The client's family asks what measures can help prevent recurrent respiratory issues. Which of the following measures should the nurse discuss to prevent respiratory issues? Select all that apply. a. Use a humidifier to moisten the air in the client's room, when needed. b. Administer a prior dosage of antibiotics when the client has a cough. c. Ambulate the client regularly, daily. d. Encourage a diet high in protein. e. Reassure the client during respiratory distress.

Ambulate the client regularly, daily., Use a humidifier to moisten the air in the client's room, when needed., Reassure the client during respiratory distress. Encourage structured activities, after learning the client's physical capabilities and provide rest periods to prevent dyspnea. Using a humidifier during drier seasons can help prevent secretions from becoming thick and difficult to expectorate. If a client is having difficulty breathing, the caregiver(s) should provide support and reassurance to decrease the client's anxiety.

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do which of the following? Select all that apply. a. Begin abdominal massage. b. Lie down in a supine position. c. Apply moist towels to the abdomen. d. Drink hot tea. e. Ensure the pouch is attached correctly.

Apply moist towels to the abdomen., Begin abdominal massage., Drink hot tea. Moist towels should be applied to the abdomen to facilitate drainage. Abdominal massage should be initiated to promote drainage. Hot tea may facilitate drainage and should therefore be encouraged.

A nurse is caring for a client who is one month post bariatric surgery and has been diagnosed with dumping syndrome. Which of the following recommendations is appropriate? Select all that apply. a. Sit up for at least an hour after each meal. b. Reduce the amount of protein and fat in the diet. c. Eliminate liquids with meals, and for one hour before and after meals. d. Avoid consuming milk, sweets, and sugars. e. Eat small, frequent meals during the day.

Avoid consuming milk, sweets, and sugars., Eat small, frequent meals during the day., Eliminate liquids with meals, and for one hour before and after meals. Dumping syndrome frequently occurs after bariatric surgery and symptoms can include vertigo, syncope, pallor, diaphoresis, tachycardia, and palpitations. Therapy includes: small, frequent meals rather than large ones; avoidance of milk, sweets, and sugars; elimination of liquids with meals and for one hour before and after meals; reduction in the amount of fluid ingested at one time, eating a high-protein, high-fat, and low-to- moderate carbohydrate diet; and lying down after meals to slow transit time of food in the intestines.

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following assessment findings should the nurse expect? Select all at apply. a. Increased appetite b. Heart rate of 52 bpm c. Digoxin level 1.5 ng/ml d. Yellow vision e. Constipation

Digoxin level 1.5 ng/ml, Heart rate of 52 bpm, Yellow vision An older adult client may experience the toxic effects of digoxin even though the drug level is within normal limits (0.5 - 1.5 ng/ml). Bradycardia is a sign of digoxin toxicity and is the reason an apical pulse is taken prior to administration of this drug. Clients with digoxin toxicity often have disturbed color vision or see halos.

A nurse is caring for a client with Crohn's Disease. Which of the following foods can be included in this client's diet? Select all that apply. a. Pasta b. Eggs c. Raisins d. Fresh celery e. Wild rice

Eggs, Pasta Low-fiber, low-residue diets are recommended for clients with Crohn's Disease. Foods that are appropriate for clients with Crohn's Disease include: Tender, ground, well-cooked meat, eggs, fish, poultry, refined pasta and cereal, white rice and bread, canned or cooked vegetables without skin or seeds and juices without pulp.

A nurse is caring for a client in Buck's Traction. Which of the following nursing interventions would ensure effective therapy? Select all that apply. a. Support the leg in adduction. b. Prevent wrinkling of the traction bandage. c. Maintain countertraction with weights. d. Ensure that all weights are free hanging. e. Assist the client to roll from side to side.

Ensure that all weights are free hanging., Prevent wrinkling of the traction bandage.

Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. Assist a client with a new transurethral prostectomy with perineal care. b. Transport a client who is utilizing oxygen and has a peripheral IV catheter. c. Obtain vital signs every 4 hours for a client with ulcerative colitis. d. Provide initial food by mouth for a client who has experienced a brain attack. e. Apply a dressing to a superficial laceration on the client's arm.

Obtain vital signs every 4 hours for a client with ulcerative colitis., Assist a client with a new transurethral prostectomy with perineal care., Transport a client who is utilizing oxygen and has a peripheral IV catheter. Assisting followers in identifying situations appropriate for delegation is considered an effective leadership function. Assisting followers to use delegation as a time management strategy and team-building tool is considered an effective leadership function. Functioning as a role model, supporter, and resource person in delegating tasks to subordinates are leadership functions that are associated with delegation.

A nurse is caring for a client hospitalized with Guillain-Barré Syndrome who has been in the intensive care unit on a ventilator for four days. Which of the following would be most appropriate in assessing for complications of immobility? Select all that apply. a. Assess the character of bowel sounds and frequency of stools. b. Observe skin color over sacral, heels, and scapulae areas. c. Assess rate and depth of respiratory effort. d. Assessing the client's ability to move lower extremities. e. Performing range of motion on the client's ankles, knees, and hips.

The correct answer is: Performing range of motion on the client's ankles, knees, and hips., Assess the character of bowel sounds and frequency of stools., Observe skin color over sacral, heels, and scapulae areas. Potential complications of immobility could include the following: loss of joint motion and contractures, decreased gastrointestinal motility and constipation, deep vein thrombosis with erythema and swelling of the calf areas, and skin breakdown with early evidence of pallor, erythema, blistering over bony prominences.

A nurse is preparing to complete discharge teaching for a hearing impaired client. Which of the following interventions would best facilitate successful teaching? Select all that apply. a. Turn off the TV and close the door to the hallway. b. Speak more loudly when talking to the client. c. Include the client's spouse in the teaching session d. Provide the client with detailed written instructions. e. Sit beside the client to discuss discharge information.

Turn off the TV and close the door to the hallway., Provide the client with detailed written instructions., Include the client's spouse in the teaching session Eliminating background noise will facilitate hearing conversational tones. Written instructions will reinforce and clarify instructions for the hearing impaired client. If the client concurs, inclusion of the spouse will be of benefit when teaching a hearing impaired client because the spouse can serve to clarify and reinforce the information after discharge.