INTEGRATED ATI FUNDAMENTALS PRACTICE EXAM A QUESTIONS AND ANSWERS
A nurse is assessing an older adult client's risk for falls. Which of the following
... [Show More] assessments should the nurse use to identify the client's safety needs? (Select all that apply).
a. lacrimal apparatus
b. pupil clarity
c. appearance of bulbar conjunctiva
d. visual fields
e. visual acuity - CORRECT ANSWER -b. pupil clarity
d. visual fields
e. visual acuity
Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Visual fields is correct. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity is correct. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
a. check the client for injuries
b. move hazardous objects away from the client
c. notify the provider
d. ask the client how she felt prior to the fall - CORRECT ANSWER -a. check the client for injuries
The first action the nurse should take would be to assess the client for injuries. All other answers are correct, but do not have priority.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
a. make sure the client's room has at least six air exchanges per hour
b. make sure the client wears a mask when outside her room if there is construction in the area
c. place the client in a private room with negative-pressure airflow
d. wear an N95 respirator when giving the client direct client care - CORRECT ANSWER -b. make sure the client wears a mask when outside her room if there is construction in the area
An allogeneic stem cell transplant compromises a client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A protective environment requires at least 12 air exchanges per hour. The nurse should place the client in a private room with positive-pressure airflow. The nurse should wear an N95 respirator when caring for clients who require airborne precautions, not a protective environment.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
a. pad the client's wrists before applying the restraints
b. evaluate the client's circulation every 8 hr after application
c. remove the restraints every 4 hr to evaluate the client's status
d. secure the restraints to the bed's side rails - CORRECT ANSWER -a. pad the client's wrists before applying the restraints [Show Less]