ATI RN Fundamentals Online Practice 2019 B with NGN

ATI RN Fundamentals Online Practice 2019 B with NGN A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? A. Client flow sheet B. Acuity ratings C. Current medications D. Incident reports - C. Current medications The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care. A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resuscitation bag with 80% oxygen prior to the procedure. B. Select a suction catheter that is half the size of the lumen. C. Place the end of the suction catheter in water-soluble lubricant. D. Adjust the wall suction apparatus to a pressure of 170 mm Hg. - B. Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? A. Place a pillow under the client's knees. B. Position a trochanter roll under each of the client's hips. C. Advise the client to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the client's feet. - D. Apply an ankle-foot orthotic device to the client's feet. The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. B. A nurse asks a nurse from another unit to assist with documentation for a client. C. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. D. A nurse discusses a client's status with the physical therapist who is caring for the client. - B. A nurse asks a nurse from another unit to assist with documentation for a client. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the container of medication prior to administration. B. Transfer the medication to a medicine cup. C. Place the client in a semi-Fowler's position prior to medication administration. D. Verify the dosage by measuring the liquid before administering it. - A. Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure that the medication is mixed. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? A. Seal unused medications from the facility in a plastic bag. B. Evaluate the client's ability to self-administer medications. C. Report an identified discrepancy to The Joint Commission. D. Compare prescriptions with medications the client received while at the facility. - D. Compare prescriptions with medications the client received while at the facility. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge. A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?" - A. "What could I have done to deserve this illness?" The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them. 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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Inject 5 units of air into the bottle of regular insulin. B. Withdraw the correct does of NPH insulin from the bottle. C. Inject 10 units of air into the bottle of NPH insulin. D. Withdraw the correct does of regular insulin from the bottle. - C. Inject 10 units of air into the bottle of NPH insulin. A. Inject 5 units of air into the bottle of regular insulin. D. Withdraw the correct does of regular insulin from the bottle. B. Withdraw the correct does of NPH insulin from the bottle. The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. Blood pressure 144/82 mm Hg - C. Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? A. Rock the client up to a standing position. B. Pivot on the foot that is the farthest from the chair. C. Assess the client for orthostatic hypotension. D. Apply a gait belt to the client. - C. Assess the client for orthostatic hypotension. The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair. A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Nurses' Notes 1000: Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs 1000: Blood pressure 132/68 mm Hg, Heart rate 99/min, Respiratory rate 20/min, Temperature 38.3° C (101° F), Oxygen saturation 96% on room air Diagnostic Results 1100: Positive throat culture for streptococci bacteria. A. Request a prescription for an antibiotic medication. B. Apply oxygen at 2 L/min via nasal cannula. C. Initiate droplet precautions. D. Wear a mask within 1 m (3 feet) of the client. E. Place the client in a negative airflow room. F. Apply a mask on the client when they leave their room. - A. Request a prescription for an antibiotic medication. The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection. C. Initiate droplet precautions. The nurse should identify that the client has streptococcal pharyngitis, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should initiate droplet precautions for the client. D. Wear a mask within 1 m (3 feet) of the client. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should wear a mask when within 1 m (3 feet) of the client to prevent the spread of the infection. F. Apply a mask on the client when they leave their room. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should apply a mask on the client when they leave their room to prevent transmission of the infection. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A. 2 cups of soup B. 1 quart of water C. 8 oz of ice chips D. 6 oz of tea - C. 8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. C. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. D. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer. - A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. Auscultate lung sounds. B. Measure urine output. C. Monitor blood pressure readings. D. Monitor electrolyte levels. - A. Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding - C. Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration. A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A. A client who has a history of physical abuse B. A client who has a permanent pacemaker C. A client who has ulcerative colitis D. A client who has asthma - D. A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma. A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? A. The caregiver is the client's financial power of attorney. B. The client is in a wheelchair with the wheels locked. C. The client reports receiving a full bath twice each week. D. The caregiver insists on remaining in the room. - D. The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. A nurse is planning care for a client who has vision loss. Which of the following