ATI RN FUNDAMENTALS EXAM Verified Q&A 2019/2020

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Face away from the client to avoid distraction -incorrect: The nurse should face the client while speaking to offer the client the opportunity to observe facial expressions and gestures. B. Pace speech to allow time for the interpreter to convey the words -The nurse should speak clearly and allow time for the interpreter to convey the message and for the client to receive it. C. Make eye contact with the interpreter when explaining the procedure -incorrect: To enhance the nurse-client relationship, the nurse should direct questions, instructions, and information to the client, not to the interpreter. The client’s focus will be on the interpreter, but it is respectful to continue to address the client and not the interpreter. D. Stand in the background while the interpreter translates the message -incorrect: The nurse should sit at the same level as the client to give the client the opportunity to observe facial expressions and gestures. A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper -incorrect: The nurse should not shake soiled linen because this action can transfer microorganisms. B. Removing a face mask when standing 0.5 m (1.6 ft) from the client -incorrect: The nurse should wear a mask when working within 1m (3.3 ft) of a client who is on droplet precautions to reduce the risk of transferring the particle droplets. C. Assigning another client with the same infection to share the room with the client -The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available. D. Allowing the client to visit a family member in the lobby of the facility -incorrect: The nurse should strictly limit the client’s activity outside the room to reduce the risk of transferring microorganisms. Whenever the client has to leave the room, the nurse should place a mask on the client. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher -Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed to move apart or away from the client. B. Instruct the client to raise his arms above his head -incorrect: The nurse should ask the client to cross his arms across his chest to avoid injuring the arms during transfer. C. Elevate the stretcher 2.5 cm (1in) above the height of the bed -incorrect: The stretcher should be no more than 1.3 cm (0.5in) above the height of the bed. D. Log-roll the client -incorrect: Log-rolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client -Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair. B. Lowering the footplates of the wheelchair before the transfer -incorrect: The AP should lower the footplates after the transfer and lift the client’s feet onto them. C. Placing the wheelchair perpendicular to the bed -incorrect: The AP should place the wheelchair parallel to the bed. D. Placing the wheelchair on the client’s weaker side prior to the transfer -incorrect: The AP should place the wheelchair on the client’s stronger side prior to the transfer to allow the client to move toward the stronger side. Nursing instructor reviewing documentation with students. Which of following legal guidelines should they follow when documenting in client record? (Select all that apply.) A: Cover arrows with correction fluid, & write in correct C: Document objective data, leaving out opinions D: Use as many abbreviations as possible E: Wait until the end of shift to document B. Put date & time on all entries, C. Document objective data, leaving out opinions reporting moderate to severe pain. Which of following actions are appropriate? (Select all B: Have another nurse listen to phone prescription hours D: Decline verbal prescription b/c it is not emergency E: Tell charge nurse that the provider has prescribed morphine by phone A. Repeat details of prescription back to provider, B. Have another nurse listen to phoneprescription, C. Obtain prescribes signature on prescription within 24 hours