ATI RN FUNDAMENTAL ONLINE PRACTICE 2019 A WITH NGN (LATEST UPDATED 2024)
A nurse on a medical-surgical unit is caring for a client who has a new
... [Show More] prescription for wrist restraints. Which of the following actions should the nurse take?
1. Pad the client's wrist before applying the restraints.
2. Evaluate the client's circulation every 8 hr after application.
3. Remove the restraints every 4 hr to evaluate the client's status.
4. Secure the restraint ties to the bed's side rails. - answers-1
The use of restraints without padding can abrade the client's skin, resulting in client injury.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
1. The client is receiving formula at room temperature.
2. The feedings infuse at a slow, continuous drip over 8 hr each night.
3. The client's caregiver washes out the feeding bag with warm water once every 24 hr.
4. The client's caregiver flushes the tubing with water before and after administering medications. - answers-3
Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination.
A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?
1. Encourage the client to relax and take deep breaths during the dressing change.
2. Educate the client about the importance of the dressing change to prevent infection.
3. Assist the client to a comfortable position for the dressing change.
4. Administer pain medication 45 min before changing the client's dressing. - answers-4
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 caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
1. Have the client wear a mask when receiving visitors.
2. Limit the client's time with visitors to no more than 30 min per day.
3. Assign the client to a room with negative-pressure airflow exchange.
4. Wear a gown when caring for the client. - answers-4
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 administering 1L of 0.9% sodium chloride to a client who is postoperative ans has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
1. Increase in hematocrit
2. Increase in respiratory rate
3. Decrease in heart rate
4. Decrease in capillary refill time - answers-3
Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
-Verify the client's name on their identification bracelet with the medication administration record
-Call the pharmacy to determine whether the client's medications are available
-Compare the clients home medications with the provider's prescriptions
-Place the client's home medication bottles in a secure location - answers-Compare the clients home medications with the provider's prescriptions
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety need? (Select all that apply)
-Lacrimal apparatus
-Pupil clarity
-Appearance of bulbar conjunctivae
-Visual fields
-Visual acuity - answers-Pupil clarity
Visual fields
Visual acuity
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
-"I can place an extension cord across my living room to plug in my television."
-"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
-"I will place my alarm clock on my bedroom dresser across the room."
-"I will replace the old throw rug in my kitchen with a new one." - answers--"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
A nurse is reviewing a client's fluid & electrolyte status. Which of the following findings should the nurse report to the provider?
BUN 15 mg/dL
Creatinine 0.8 mg/dL
Sodium 143 mEq/L
Potassium 5.4 mEq/L - answers-Potassium 5.4 mEq/L
A nurse is admitting a client who has an abdominal wound with a large amount of purple tissue drainage. Which of the following types of transmission precautions should the nurse initiate?
Protective environment
Airborne precautions
Droplet precautions
Contact precautions - answers-Contact precautions
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
-Discuss the risk factors for colon cancer.
-Focus teaching on what the client will need to do in the future to manage his illness.
-Provide the client with written information about the phases of loss & grief.
-Reassure the client that this is an expected response to grief. - answers--Reassure the client that this is an expected response to grief.
A nurse is caring for a client who is postoperative following a knee arthroplasty & requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
-Assist the client into a prone position
-Place a sleeve over the top of each leg with the opening at the knee
-Make sure two finger can fit under the sleeves
-Set ankle pressure at 65 mmHg - answers--Make sure two finger can fit under the sleeves
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use?
Alienate
Gauze
Transparent
Hydrocolloid - answers-Hydrocolloid
A nurse is preparing an education program for the staff about advocacy. Which of the following information should the nurse include?
-Advocacy ensures clients' safety, health, & rights.
-Advocacy series that nurses are able to explain their own actions.
-Advocacy ensures that nurses follow through on their promises to clients.
-Advocacy ensures fairness in client care delivery and use of resources. - answers-Advocacy ensures clients' safety, health, & rights. [Show Less]