ATI Fundamentals B Final

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? A Droplet B. Airborne C. Contact D. Protective Environment

A. Droplet

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? A. Erythema on pressure points B. Lower extremity pulse strength of 2+ C. Fluid intake of 3,000mL per day D. One bowel movement every other day

A. Erythema on pressure points

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat, for a patient who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record? A. .3mg B. 0.3mg C. 0.30mg D. 3/10mg

B. 0.3mg

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? A. Admitting diagnosis B. Breath Sounds C. Body Temp D. Diagnostic test results

B. Breath Sounds

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings B. Tell the client to keep the head of the bed elevated at least 30* C. Make sure the eternal formula is at room temp D. Wipe the top of the formula can with alcohol

B. Tell the client to keep the head of the bed elevated at least 30*

A nurse is caring for a client who has a prescription for a wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing the old dressing B. Warm the irrigation solution to 40.5*C (105*F) C. Cleanse the wound from the center outward D. Use a 20-mL syringe to irrigate the wound.

C. Cleanse the wound from the center outward

A nurse enters a clients room and finds her on the floor. The clients roomate reports that the client was trying to get out of bed and fell over the bedside rail onto the floor. Which of the following statements should the nurse document about this incident? A. Incident report completed B. Client climbed over the side rails C. Client found on floor D. Client was trying to get out of bed

C. Client found on floor

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? A. I had a bowel movement, but I was able to save the urine B. I have a specimen in the bathroom from about 30 min ago C. I flushed what I urinated at 7am and have saved all urine since D. I drink a lot, so I will fill up the bottle and complete the test quickly

C. I flushed what I urinated at 7am and have saved all urine since

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? A. Seal unused medications from the facility in a plastic bag B. Evaluate the clients ability to self administer medications C. Report an identified discrepancy to The Joint Commission D. Compare prescriptions with the medications the client received while at the facility

D. Compare prescriptions with the medications the client received while at the facility

A charge nurse is discussing the responsibility of the nurses caring for clients who have a Clostridium defficile infections. Which of the following should the nurse include in the teaching? A. Assign the client to a room with negative airflow 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. Have family members wear a gown and gloves when visiting

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? A. You should have an eye examination every 2 years B. You should receive a tetanus booster every 5 years C. You should receive a shingles vaccine when you are 70 years old D. You should receive a pneumococcal vaccine when you are 65 years old.

D. You should receive a pneumococcal vaccine when you are 65 years old.

A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? A Ambulating a client post op B. Inserting an indwelling urinary catheter for a client C. Demonstrating the use of an incentive spirometer to a client D. Confirming that a clients pain has decreased after recieving an analgesic

A Ambulating a client post op

A nurse is providing discharge teaching for a client who has a new prescription fro a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family (SATA)? A. Check the cord routinely for frays or tearing B. Keep the unit at least 1.2m (4ft) away from a gas stove C. Concider purchasing a generator for power backup D. Observe for signs of hypoxia E. Select synthetic clothing and bedding

A. Check the cord routinely for frays or tearing C. Concider purchasing a generator for power backup D. Observe for signs of hypoxia

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesic (PCA) pump. Which of the following actions should the nurse take? A. Instruct the family to refrain from pushing the button for the client while she is a sleep B. Inform the client that because she is on a PCA, vital signs will be taken every 8hrs C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10 D. Increase the basal rate and shorten the lock out interval time if the patients pain level is too high

A. Instruct the family to refrain from pushing the button for the client while she is a sleep

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? A. Place the client in a room with negative pressure airflow B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2 hr incriments D. Wear surgical mask when providing client care E. Use antimicrobial sanitizer for hand hygiene

A. Place the client in a room with negative pressure airflow B. Wear gloves when assisting the client with oral care E. Use antimicrobial sanitizer for hand hygiene

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? A. When descending stairs, I will first shift my weight to my right leg B. I should place my crutches 12 inches in front and to the side of each foot C. As I sit down I will hold one crutch in each hand D. I will make sure the shoulder rests are snug against my armpits

A. When descending stairs, I will first shift my weight to my right leg

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A. Ask the client to consider a direct donation B. Withhold the blood tranfusion C. Request a consultation with the ethics committee D. Ask the clients family to intervene

B. Withhold the blood tranfusion

A nurse is calculating a clients fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the clients intake and output record as 120mL of fluid? A. 2 cups of soup B. 1qt of water C. 8oz of ice chips D. 6oz of tea

C. 8oz of ice chips

A nurse is caring for a client with an indwelling catheter. Which of the following findings indicates that the catheter requires irrigation? A. Urine has an unusual odor B. Urine specific gravity is 1.035 C. Bladder scan shows 525mL of Urine D. Urine is positive for ketones

C. Bladder scan shows 525mL of Urine

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? A. Neck vein distention B. Urine specific gravity C. Rapid heart rate D. BP 144/82 mm Hg

C. Rapid heart rate