RN Fundamentals Online Practice 2022 B
1. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium
difficile
... [Show More] infection. Which of the following information should the nurse include in the teaching?
Answer: Have family members wear a gown and gloves when visiting.
Rationale:
Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the
transmission of Clostridium difficile spores. Staff must also wear gowns 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 for the nurse to provide?
Answer: Breath sounds
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should determine that 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 a client who is postoperative
Rationale: Ambulating a client is within the range of function of an AP. The nurse can delegate
tasks to the AP that do not require special skills, assessment, or teaching.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports 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 or cause.
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: Cleanse the wound from the center outward. [Show Less]