Fundamentals ATI Practice B
A charge nurse is discussing the responsibility of nurses caring for clients who
have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution
d. have family members wear a gown and gloves when visiting
d. have family members wear a gown and gloves when visiting
A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary.
Use alcohol-based hand sanitizer when leaving the client's room. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores.
Clean contaminated surfaces in the client's room with a phenol solution.The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores.
Have family members wear a gown and gloves when visiting.Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis
b. breath sounds
c. body temperature
d. diagnostic test results
b. breath sounds
When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. Knowing the client's admitting diagnosis is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Body temperature
Knowing the client's current body temperature is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Knowing diagnostic test results is essential for planning care and following critical pathways; however, other information is the nurse's
priority to provide.
6 Ways to Show Appreciation for Your Child's Teacher
A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate?
a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic
a. ambulating a client who is postop
Ambulating a client is within the range of function of an AP . The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.
Inserting an indwelling urinary catheter for a clientIndwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This task is outside the range of function of an AP .
Demonstrating the use of an incentive spirometer to a clientClient education requires advanced nursing knowledge and is outside the range of function of an AP .
Confirming that a client's pain has decreased after receiving an analgesicEvaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP .
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on the floor" d. "client was trying to get out of bed"
c. "client found lying on the floor"
An incident report is an internal document that is part of a facility's risk management system. The nurse should not document completion of an incident report in the client's medical record for the facility's protection in the event of litigation.
"Client climbed over the side rails."Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an objective account of the nurse's findings.
"Client found lying on floor." The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives
or cause.
"Client was trying to get out of bed."Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective account of the nurse's findings. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound.
c. cleanse the wound from the center outward
The nurse should wear clean gloves to remove the old dressing.
Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the irrigation solution to body temperature.
Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.
Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.
A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet
b. airborne
c. contact
d. protective environment
a. droplet
Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.
Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
A charge nurse is discussing the responsibility of nurses caring for clients who
have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution
d. have family members wear a gown and gloves when visiting
d. have family members wear a gown and gloves when visiting
A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary.
Use alcohol-based hand sanitizer when leaving the client's room. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores.
Clean contaminated surfaces in the client's room with a phenol solution.The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores.
Have family members wear a gown and gloves when visiting.Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis
b. breath sounds
c. body temperature
d. diagnostic test results
b. breath sounds
When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. Knowing the client's admitting diagnosis is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Body temperature
Knowing the client's current body temperature is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Knowing diagnostic test results is essential for planning care and following critical pathways; however, other information is the nurse's
priority to provide.
6 Ways to Show Appreciation for Your Child's Teacher
A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate?
a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic
a. ambulating a client who is postop
Ambulating a client is within the range of function of an AP . The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.
Inserting an indwelling urinary catheter for a clientIndwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This task is outside the range of function of an AP .
Demonstrating the use of an incentive spirometer to a clientClient education requires advanced nursing knowledge and is outside the range of function of an AP .
Confirming that a client's pain has decreased after receiving an analgesicEvaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP .
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on the floor" d. "client was trying to get out of bed"
c. "client found lying on the floor"
An incident report is an internal document that is part of a facility's risk management system. The nurse should not document completion of an incident report in the client's medical record for the facility's protection in the event of litigation.
"Client climbed over the side rails."Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an objective account of the nurse's findings.
"Client found lying on floor." The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives
or cause.
"Client was trying to get out of bed."Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective account of the nurse's findings. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound.
c. cleanse the wound from the center outward
The nurse should wear clean gloves to remove the old dressing.
Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the irrigation solution to body temperature.
Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.
Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.
A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet
b. airborne
c. contact
d. protective environment
a. droplet
Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.
Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
