ATI B Exam
A nurse enters a client's room and finds her on the floor. The client's roommate reports that she 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 the floor"
A nurse is caring for a client who requires 24 hour urine collection. Which of the following statements made by the client indicates understanding?
"I flushed what I urinated at 7:00 am and have saved the rest of the urine since"
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse Identify as an indication that the client understands the teaching?
"When descending stairs, I will first shift my weight to my right leg"
Nurse caring for a client with TB. Which of the following actions should she take?
-Place client in a room with negative-pressure airflow -Wear gloves when assisting the client with oral care -Use antimicrobial sanitizer for hand hygiene
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following should the nurse delegate?
Ambulating a patient who is postoperative
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 reveals 525 mL of urine.
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following is the priority for the nurse to report?
Breath sounds
The nurse is providing discharge teaching for a client who has a new rx for a home o2 concentrator. Which instructions should the nurse provide to him and his family?
Check the cord routinely for frays or tearing Keep unit at least 8 ft away from gas stove Consider purchasing a generator for power backup Observe for signs of hypoxia
A nurse on a medical unit is preparing to discharge a client to home. which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions w/ medications the client received during hospitalization
A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting
D
Rubella would require which precaution?
Droplet
A nurse is assessing an adult client that has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?
Erythema on pressure points
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which should the nurse do FIRST?
Tell the client to keep the HOB elevated to at least 30 degrees.
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
The nurse should clean the wound from the center outwards to prevent introduction of microorganisms from the outer skin surface
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 should the nurse do?
Withhold the blood transfusion.
