ATI Capstone Fundamentals 1

A nurse is caring for an older adult client who has constipation . Which of the following actions should the nurse take ?

Add fluid and fiber to the diet

A nurse is reviewing a provider's prescriptions for a group of clients . Which of the following client prescriptions should the licensed practical nurse clarify with the provider ? (LPN)

Administer 1 g of vancomycin intrathecally .

A nursing is caring for a client who presents to an urgent care with a laceration on his forearm . Which of the following activities is an example of primary prevention ?

Administering a tetanus immunization

What precautions are used for MTV, Herpes Zoster

Airborne

A nurse is caring for a client who reports an area of redness , warmth , tenderness and pain in the right calf . Which of the following actions should the nurse anticipate when notifying the provider of this finding ?

Arrange for a venous duplex ultrasound .

A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies . Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses ?

Biofeedback

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and is progressing from a clear liquid diet to a full liquid diet . The nurse should remind the client that which of the following items is included in a full liquid diet ?

Chocolate pudding

A nurse is caring for a client who has a stage - 3 pressure ulcer that now has some granulating tissue . Which of the following interventions should the nurse recommend for inclusion in the plan of care ?

Cleanse with 0.9 % sodium chloride irrigation

A nurse is verifying that a client is giving informed consent to undergo electroconvulsive therapy . Which if the following actions should the nurse take ?

Confirm signature is authentic

What precautions are used for pertussis and CDiff

Contact precautions

A nurse is assisting in preparing a presentation at a senior center about age - related musculoskeletal changes . Which of the following alterations is appropriate for the nurse to include ?

Decreased muscle mass

An action that increases the angle between two connecting bones Extension of the fingers would be to straighten the fingers of the hand

Extension

Flexion is an action that decreases the angle between two connecting bones . Flexion of the fingers would be making a fist with the hand

Flexion

A nurse is preparing a sterile field for the insertion of a urinary catheter . Identify the sequence of actions the nurse should follow . ( Move the steps into the box on the right , placing them in the selected order of performance . Use all the steps . )

Hand hygiene, place package on work surface, open outermost flap, side flaps, then inner most flap toward body

A nurse is reinforcing home safety information with an older adult client . Which of the following statements should the nurse identify as an indication that the client needs further instruction ?

I should use my walker carefully when going upstairs .

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home . Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions ?

I will position the head of the bed 45 degrees during the feeding

A nurse is implementing a bladder - training program for a client . For which of the following actions by the assistive personnel ( AP ) who is helping with the client's care should the nurse intervene ?

Instructs the client to urinate whenever the urge occurs

A nurse is talking with a client who has a new diagnosis of acute bursitis in her right shoulder . Which of the following self - care strategies should the nurse recommend ?

Intermittent ice and heat

When are droplet precautions used

Measles, Influenza, Mumps, Respiratory illnesses

A nurse is participating in an interdisciplinary treatment meeting for a client who is to go home within a week . Which of the following health care providers should the nurse identify will assist the client with activities of daily living ?

Occupational therapist

Assist with strength training improve movement

Physical Therapist

A nurse is collecting data from a client who has venous insufficiency . Which of the following findings should the nurse expect ?

Pitting edema

A nurse working on a medical - surgical unit suspects that several clients have Clostridium difficile when they all develop watery diarrhea . Which of the following actions should the nurse plan to take while waiting for the client's lab results

Place all clients who have manifestations on contact precautions .

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel . Which of the following information should the nurse include in the plan ?

Provide the client a diet high in vitamin C

A nurse in a long - term care facility enters the day room and finds the window curtains on fire . Clients are panicking and the room is filling with smoke . Indicate the emergency actions the nurse must take . ( Move the steps into the box on the right , placing them in the selected order of performance . Use all the steps .

RACE to prioritize the actions to take : R - Rescue and remove the clients , A- Activate the alarm , C- Confine the E- Extinguish the fire .

A nurse is caring for a group of clients on a medical - surgical unit . Which of the following actions jeopardize client confidentiality ? ( Select all that apply . )

Sharing a personal password with a coworker, Discussing clients at the table in the cafeteria ,Disposing of written report sheet into the facility trash receptacle

A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy . The nurse should explain that which of the following medications can put clients at risk for hyperkalemia ?

Spironolactone

A nurse is assigned care of a client who has HIV . Which of the following infection control precautions should the nurse plan to use while caring for this client ?

Standard Precautions

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion . The client has no other dietary restrictions . Which of the following foods should the nurse select as a component of the client's meals ?

Steamed Vegetables

A nurse is planning to perform passive range of motion for a client who is immobilized . Which of the following actions should the nurse plan to take ?

Support extremities above and below joints .

A nurse on an inpatient mental health unit is caring for a group of clients . Which of the following actions by the nurse demonstrates the ethical concept of autonomy ?

Supporting a client's wishes to refuse prescribed treatments

A nurse is caring for a client who is unconscious . With the help of an assistive personnel , the nurse has repositioned the client from a left lateral to a right lateral position . The client's daughter asks why the nurse keeps her father lying on his side . Which of the following rationales should the nurse give the family member ?

To prevent aspiration problems

A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development . Identify the order of Erikson's stages of psychosocial development from birth through 18 years of . ( Move the steps into the box on the right , placing them in the selected order of performance . Use all the steps . )

Trust vs. mistrust ( birth -1 year )autonomy vs. shame and doubt between (1 - 3 years ). (3- 6 years ) initiative vs. guilt stage , industry inferiority( 6 -11 years ). identity vs. role confusion (puberty)

A nurse is collecting data from a client who has hypokalemia as a result of nausea , vomiting , and diarrhea . Which of the following findings should the nurse expect ?

Weak,irregular pulse

A nurse is reinforcing teaching to a group of older adults about sources of complete and incomplete protein . Which of the following foods should the nurse include as a complete protein ?

Yogurt

Who assist the client with obtaining resources to assist with issues such as finances , nutrition , transportation , and in - home care .

social worker