ATI RN fundamentals (Form A and B) Merged Graded A 2023

A nurse is planning to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? Use a clock pattern to describe food on the client's plate. Describing the location of food using clock pattern allows client to have greater independence during meals. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? Allow extra time for the client to respond to questions. Older adults often process information at slower rate than younger clients - allow extra time to allow client to ask questions and absorb information A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select ALL that apply. Place the client in a room with negative-pressure airflow - airborne precautions Wear gloves when assisting the client with oral care - standard precautions. Use antimicrobial sanitizer for hand hygiene - wash hands with soap & water when visibly soiled. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 10 units of air into the bottle of NPH insulin. Inject 5 units of air into the bottle of regular insulin. Withdraw the correct dose of regular insulin from the bottle. Withdraw the correct dose of NPH insulin from the bottle. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? Rapid heart rate Tachycardia indicates fluid-volume deficit - expected Urine specific gravity would be > 1.030 Hypotension A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? Auscultate lung sounds. ABCs - monitor for fluid-volume excess Moist crackles in lungs, dyspnea, SOB A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning." verbalizing best time for him to learn. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? Contact precautions Major wound infections require contact precautions - admit client to private room. Caregivers should wear gown & gloves during direct contact. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? Initiate an enteral feeding through a gastrostomy tube. Initiate feedings through nasoenteric, gastrostomy, and jejunostomy tubes. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Cleanse the wound from the center outward. Prevent introduction of micro-organisms from the outer skin surface. A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should report which of the following client statements? "The pain is like a dull ache in my stomach." Describing quality of pain A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? Use progressive relaxation techniques at bedtime. promotes sleep by decreasing stress & reducing muscle tension. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? Determine the reasons why the client is refusing to use the incentive spirometer. 1st - Assess A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? Flush the tube with 15 mL of sterile water. Flush with 15-30 mL of sterile water before administration and between each medication. Flush feeding tube with 30-60 mL of sterile water following administration of last medication.