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ATI Fundamentals Proctored Exam Patient Care and Safety Part 2

Nursing50 CardsCreated 4 months ago

When a client presents with right lower quadrant pain, nausea, and vomiting, the nurse should auscultate bowel sounds first to avoid altering assessment findings before other interventions. A statement such as "I don’t know if I will be able to meet his physical needs" indicates maladaptive coping, reflecting emotional distress and lack of confidence in caregiving abilities.

a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
a. Offer pain medication
b. Palpate the abdomen c.Auscultate bowel sounds
d.Administer an antiemetic

c

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Term
Definition

a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
a. Offer pain medication
b. Palpate the abdomen c.Auscultate bowel sounds
d.Administer an antiemetic

c

A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the
following statement by the client partner indicates maladaptive coping?
a. I don't know of if I will be able to meet his physical needs.

a

A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse
should anticipate application of which of the following dressings?
a. Dry gauge
b. Transparent
c. Calcium alginate
d. Hydrogel

b

A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse?
a. "lets discuss your concerns about your father," or anything along those lines that is
therapeutic.

a

a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?
a. I can apply lotion to soften the calluses as long as I don't put lotion between my toes
b. I can place an oval corn pad over toes that have corns as longs as a remove the pad
weekly
c. I should soak my feet in warm water daily to soften corns and calluses
d. I should use an over the counter liquid medication to remove corns

a

A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?
a. Tie the restraints to the side rail b. Secure restraints with a square knot
c. Remove one restraint at a time
d. Remove the restraints every 3 hours

c

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TermDefinition

a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
a. Offer pain medication
b. Palpate the abdomen c.Auscultate bowel sounds
d.Administer an antiemetic

c

A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the
following statement by the client partner indicates maladaptive coping?
a. I don't know of if I will be able to meet his physical needs.

a

A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse
should anticipate application of which of the following dressings?
a. Dry gauge
b. Transparent
c. Calcium alginate
d. Hydrogel

b

A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse?
a. "lets discuss your concerns about your father," or anything along those lines that is
therapeutic.

a

a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?
a. I can apply lotion to soften the calluses as long as I don't put lotion between my toes
b. I can place an oval corn pad over toes that have corns as longs as a remove the pad
weekly
c. I should soak my feet in warm water daily to soften corns and calluses
d. I should use an over the counter liquid medication to remove corns

a

A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?
a. Tie the restraints to the side rail b. Secure restraints with a square knot
c. Remove one restraint at a time
d. Remove the restraints every 3 hours

c

A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply
a. Use an N95 respirator while providing client care
b. wear a gown and gloves when providing client care
c. assign the client to a private room with positive air flow
d. wash hands with soap and water after contact with the client
e. Ensure the client does not receive fresh fruits

b, c, d

A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?
a. Schedule the client as the first surgical procedure of the day
b. Cleanse the stoppers with primidone iodine for withdrawing medication
c. Remove the stop stocks from iv tubing
d.Ensure the gloves in the surgical suite are powdered gloves

a

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following action should the nurse take?
a. direct verbal discharge instruction to the interpreter

a

A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?
a. The client's belief that his needs will be met through education
b. The nurse explaining the need for education to the client
c. The client seeking family approval by agreeing to a teaching plan
d. The nurse's empathy about the client having to self-inject

a

A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?
a. Heat the formula to 105 degrees Fahrenheit
b. Flush the tubing with 10 ml of water every 2 hours
c. Change the tubing every 72 hours
d. Aspirate residual volume every 4 hours (Every 4-8 hours is correct)

d

A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following answers indicates the proper method of cleaning a wound site?
a. use a different sterile swab for each stroke

a

A nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?
a. The client picks up the walker with each step
b. The client stoops slightly forward when moving the walker
c. The client stands with her elbows slightly flexed while holding the walker
d. The client moves the walker ahead 10 inches with each step (Incorrect b/c 6 inches max)

c

A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?
a. Libel
b. Defamation of character
c. Assault
d. Battery

c

A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?
a. Stabilize the vein by applying traction above the insertion site
b. Engorge the vein by placing the arm in the dependent position
c. Use friction at the insertion site to increase venous distention d.Leave the tourniquet on for 30 to 60 seconds after initial insertion

b

A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
a. Prepare the client for a central venous line
b. Change the PN infusion bag every 48 hours
c. Administer the PN and fat emulsion separately
d. Obtain a random blood glucose daily

a

A nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don't understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take?
a. Provide brochures about the procedure
b. Notify the provider
c. Complete an incident report
d. Describe the surgery to the client

b

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts?
a. False imprisonment
b. Invasion of privacy
c. Assault
d. Negligence

a

A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take?
a.Place an activated tuning fork in the middle of the client's head

a

A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield.
a. Changing the brief of an older client who has Clostridium difficile

a

An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?
a. Use the television to mask external noises
b. Listen to soft music before lying down
c. Exercise just prior to bedtime d.Keep the sleeping environment warm

b

A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her provider. Which of the following is an appropriate response by the nurse?
a. You should ask the provider if she recommend traditional Chinese medicine.

a (probs not)

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
a. Eat a light carbohydrate snack before bedtime
b. Exercise 1 hour before bedtime
c. Drink a cup of hot cocoa before bedtime
d.Take a 30 min nap daily

a

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?a. Each element has a range 1 to 5 points
b. The higher the score the higher the pressure ulcer risk
c. The clients age is part of the measurement
d. The scale measures six elements

d

A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
a. Ensure the client is free of metal objects
b. Administer 240 ml (8oz) oral contrast before the procedure
c. Monitor the client for pain in the suprapubic region
d. Assist the client with a bowel cleansing

a

A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include
a. I don't know of if I will be able to meet his physical needs.

a

A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest.
Which of the following should the nurse take to obtain the sample?
a. The pad of the finger tip
b. The lateral aspect of the finger c. The pinna of the ear
d. The side of the wrist

b

A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first?
a. Provide the client with a contact number for a diabetes education specialist
b. Make a copy of the medication record of the reconciliation for the client
c. Determine whether the client can afford the insulin administration supplies
d. Obtain printed information about self-administration

c

A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?
a. Wear a mask when working within 3 feet of the client

a

A nurse is delegating client's care to the assistive personnel. Which of the following tasks should the nurse delegate to the AP?
a. obtain input & output for the patient that was stable, ADLs, specimen collection, I&O, vital signs if stable

a

A nurse is teaching about home safety with. Which of the following instructions should the nurse include?
a. Use electrical tape to secure extension cords next to base boards on the floor
b. Replace carpet floors with tiles
c. Unplug electronics by grasping the cord
d. To use a fire extinguisher, aim high at the top of the flames

a

A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first?
a. Elimination needs
b. Comfort level
c. Peripheral pulses
d. Skin integrity

c

A nurse in a long-term care facility is assessing a client. Which of the following findings should the nurse recognize as an indication a fecal impaction?
a. Seepage of liquid stool

a

A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take?
a. Cotton tip applicator to clean the inside of the cannula
b. Soak the outer cannula in warm soapy tap water
c. Cleanse the skin around the stoma with normal saline
d. Secure the tracheostomy ties to allow one finger to fit snuggly underneath

d

A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse?
a. I don't know of if I will be able to meet his physical needs.

a

A nurse is preparing to transfer a client who is partially weight bearing from the bed to a chair. Which of the following action should the nurse
a. Have the client bear weight on her stronger leg

a

A nurse in an acute care facility is preparing to transfer a client to a long-term facility. Which of
the following information should be nurse include in the hand off report?
a. Effectiveness of the last dose of pain medication

a

A nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the following statements by the client indicates understanding of the teaching?
a. I will keep my eyes closed for 5 mins after inserting drops
b. I will insert the drops in the center of the eye
c. I will press the inner corner of my eye after insert
drops
d. I will raise my eye lid up while looking down and insert drops

c

A nurse in a long-term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer?
a. A client who is incontinent of urine 1 to 2 times a day
b. A client who is receiving enteral tube feedings
c. Client who requires assistance to transfer from the bed to a chair d. Client who is unresponsive to pain stimuli

d

A nurse is assessing a client's personal hygiene. Which of the following findings indicates that the client might have difficulty with routinely bruising their teeth?
A. Theclientsmucosaismoist
B. The client gums feel spongy
C. The client has a missing tooth
D. The Client's tongue is a dull red color

b

A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first?
A. Make a copy of the medication reconciliation form for the client
B. Provide the client with the contact number for a diabetes education specialist
C. Determine whether the client can afford the insulin administration supplies
D. Obtain printed about insulin self administration

c

A community health nurse is teaching a group of clients about kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include?
A. Contact your pelvic muscle when performing the exercises
B.Expect improvement after 2 weeks of performing the exercises C. Hold your breath when performing the exercises
D. Tighten your buttocks when performing the exercises

a

A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?
A. Skin tags noted in the neck region
B. A change in appearance of a mole on the shoulder
C. A flat, nonpalpable, discovered area of skin on the trunk
D. Atrophic wart on the left index finger

b

A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?
A cover the client with heavy blankets after shivering subsides
B place ice packs on the clients neck and behind the knees
C apply a bath blanket between the client and a cooling blanket
D give the client a sponge bath using alcohol water solution

c

A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of the following individuals should sign the consent form?
A. The infants 17 year old mother
B. The infants provider
C. The infants grandmother
D. The mother's 21 year old sibling

a

A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use?
A. Encourage the client to try to defecate for 20 min while on the fracture pan.
B. Keep the bed flat while the client is on the fracture pan.
C. Hyperextend the clients back while the fracture pan is in place.
D. Place the shallow end of the fracture pan under the clients buttocks.

d

A nurse is reviewing the medical record of a client who asks about the use of a
magnet therapy for pain relief. The nurse should identify which of the following findings is a contraindication for receiving this type of therapy?
A. The client is allergic to penicillin B. The client has a prescription for metoprolol
C. The client has a history of alcohol use disorder
D. The client has an implanted defibrillator

d

A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the clients room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
A. Gloves
B. Eyewear
C. Gown
D. Mask

a

A nurse is teaching a newly licensed nurse about the care of a client who has
methicillin resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a. I will wear an N95 respirator mask when caring for the client
b. I will tell the clients visitors to wear a mask when they are within 3 feet of the client.
c. I will place the client in a private room
d. I will remove my gown before my gloves after providing client care.

c

A charge nurse in a long term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
A. Delirium has an abrupt onset

a