ATI Fundamentals Proctored Exam Patient Care and Safety Part 2
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
Key Terms
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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| 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? | c |
A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the | a |
A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse | 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 |
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 |
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? | 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 | 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 |
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 |
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 |
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? | 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 |
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? | 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? | 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? | 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 |
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? | 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 |
A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take? | 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 |
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? | 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 (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 |
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 | 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 |
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 |
A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. | 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? | 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 |
A nurse is delegating client's care to the assistive personnel. Which of the following tasks should the nurse delegate to the AP? | a |
A nurse is teaching about home safety with. Which of the following instructions should the nurse include? | a |
A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first? | 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 |
A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? | 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 |
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 |
A nurse in an acute care facility is preparing to transfer a client to a long-term facility. Which of | 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? | 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? | 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? | 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? | 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 |
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? | b |
A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take? | 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 |
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? | d |
A nurse is reviewing the medical record of a client who asks about the use of a | 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 |
A nurse is teaching a newly licensed nurse about the care of a client who has | 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 |