NGN ATI RN Fundamentals NURSING Online Practice EXAM LATEST 2023 A+ GRADE
1.A charge nurse is discussingthe responsibility of nurses caring forclients
... [Show More] who havea Clostridium difficile infection. Which of the following information should the nurse include in the teaching? Answer: Have family members wearagown and gloves when visiting.
Rationale:
Nurses are responsibleforensuring that family memberswearagown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also weargowns and gloves.
2.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 forthe nurse to provide? Answer: Breath sounds
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determinethat the priority information to provide is the current status of the client's breath sounds.
3.A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
Answer: Ambulating aclient who is postoperative
Rationale: Ambulating aclientis within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, orteaching.
4.A nurse enters aclient’s room and findsheron the floor. The client’s roommatereports that the client 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?
My answer: “Client was trying to get out of bed.” Answer: "Client found lying on floor."
Rationale: The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives orcause.
5.A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Answer: Cleansethe woundfrom the center outward.
Rationale: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outerskin surface. The nurse shouldwearclean gloves to remove the old dressing, not sterile gloves. The nurse should warm the irrigation solution to body temperature.
The nurse should use a 35-mL syringe to irrigate the wound. Syringesthat hold 30 to 60 mL of fluid create asafe but effectiveamount of pressure forwound irrigation.
6.A nurse is admitting aclient who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
My answer: Airborne Answer: Droplet
Rationale: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement forclients who haveinfections that spread via droplet nucleithat are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
7.A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of thefollowing instructions should the nurseprovide to the client and his family? (Select all that apply.)
Answer: Check the cord routinelyforfrays ortearing; consider purchasing agenerator forpower backup; observe for signs of hypoxia
Rationale: Oxygen concentrators require electrical power. Safe use of this delivery system
includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even withsupplemental oxygen, theclient's status can worsen, resulting in the development of hypoxia.
8.A nurse is calculating aclient’s fluidintakeover the past 8 hr. which of the following items should the nurse plan to document on the client’s intake and output record as 120 mL of fluid? Answer: 8oz of ice chips
Rationale: The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid wateris equal to 120 mL of fluid.
9.A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)
Answer: Place the client in aroom with negative-pressure airflow; weargloves when assisting the client with oral care; use antimicrobial sanitizer for hand hygiene
Rationale: The nurse should place the client in a room with negative-pressure airflow to meet
the requirements of airborne precautions. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. The nurseshould use antimicrobialsanitizer forroutine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled. The nurse should wear an N95 respirator during client care to meet the requirements of airborneprecautions.
10.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 actions should the nurse take?
Answer: Withholdthe bloodtransfusion.
Rationale: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.
11.A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statementsshould the nurse identify as an indicationthat the client understands the teaching?
My answer: "I will make sure the shoulder rests are snug against my armpits." Answer: "When descending stairs, I will first shift my weight to my right leg."
Rationale: To descend stairs, theclient should first shifthis body weight to his right, unaffected leg.
To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2
in) below the axillae. Just beforesitting down, the client shouldhold both crutches by theirhand bars in one hand. The client should place his crutches 15 cm (6 in) in front and to the side of each foot.
12.A nurse has accepted a verbal prescription “for three tenths of a milligram of levothyroxine IV stat” fora client who has myxedema coma. How should the nurse transcribethe dosageof this medication in the client’s medicalrecord?
Answer: 0.3 mg
Rationale: The use and placement of adecimal point can potentiallycause amedicationerrorif documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow adecimal point unless awhole number followsthe zero, as in 2.05 mg.
13.A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? [Show Less]