ATI Week 2 Exam

ATI Week 2 Exam A nurse is preparing to assist a patient with a tub bath. Identify the sequence of steps the nurse should take. Answer- 1. Gather all necessary supplies 2. place a rubber mat on the tub floor 3. assist the patient into the bathroom 4. Instruct the patient on using safety bars when getting in and out of the tub 5. Instruct the patient to remain in the tub for no longer than 20 min When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include? Answer- Ask the patient in what order she typically performs her morning routine A nurse is caring for a patient who is on long-term bedrest and requires linen changes due to excessive diaphoresis. What is the priority rationale for frequent linen changes? Answer- Moisture from excessive diaphoresis can cause skin breakdown. A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. What is an appropriate response by the nurse? Answer- "Oral care is still important even though you are not eating." A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task? Answer- The AP reuses the patient's blanket and spread While performing a complete bed bath for a patient, the nurse should: Answer- raise the room temperature A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection? Answer- Cleaning the least-soiled areas prior to cleaning the most-soiled areas. A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient? Answer- "I'll swab the patient's mouth with diluted hydrogen peroxide" What is your primary goal in performing a comprehensive physical assessment? Answer- To develop a plan of care While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following is a normal sounds?