ATI Fundamentals Test Exam 11 2024 VERIFIED
A+ WITH CORRECT QUESTION AND ANSWERS
AFnurseFisFadministeringF1FLFofF0.9%FsodiumFchlorideFtoFaFclientFwhoFisFpostoperativeFandFhasF
fluidFvolumeFdeficit.FWhichFofFtheFfollowingFchangesFshouldFtheFnurseFidentifyFasFanFindicatio
nFthatFtheFtreatmentFwasFsuccessful?
IncreaseFinFhematocritFincreas
eFinFrespiratoryFrateFDecreaseFi
nFheartFrate
DecreaseFinFcapillaryFrefillFtimeF-FCorrectFAnswer:
DecreaseFinFheartFrate
FluidFvolumeFdeficitFcausesFtachycardia.FWithFcorrectionFofFtheFimbalance,FtheFheartFrateFshoul
dFreturnFtoFtheFexpectedFrange.
IncorrectFAnswers:
IncreaseFinFhematocrit:
FluidFvolumeFdeficitFcausesFanFincreaseFinFhematocritFlevelFdueFtoFdepletionFofFextracellularFflu
id.FWithFcorrectionFofFtheFimbalance,FtheFhematocritFlevelFshouldFdecrease.
increaseFinFrespiratoryFrate
FluidFvolumeFdeficitFcausesFanFincreaseFinFrespiratoryFrate.FWithFcorrectionFofFtheFimbalance,Ft
heFrespiratoryFrateFshouldFreturnFtoFtheFexpectedFrange.
DecreaseFinFcapillaryFrefillFtime
FluidFvolumeFdeficitFslowsFcapillaryFrefill.FWithFcorrectionFofFtheFimbalance,FcapillaryFrefillFti
meFshouldFreturnFtoFtheFexpectedFrange.
AFnurseFisFcaringFforFaFclientFwhoFisFscheduledFtoFbeFtransferredFtoFaFlong-
termFcareFfacility.FTheFclient'sFfamilyFquestionsFtheFnurseFaboutFtheFreasonsFforFtheFtransfer.FW
hichFofFtheFfollowingFresponsesFmadeFbyFtheFnurseFisFappropriate?
"TheFtransferFofFyourFfamilyFmemberFisFbeingFdoneFbecauseFtheFproviderFknowsFwhat'sFbest."F"
WouldFyouFlikeFitFifFweFdiscussedFtheFtransferFwithFyourFfamilyFmember?"
"WhyFareFyouFsoFconcernedFaboutFthisFtransfer?"
"IFknowFhowFyouFfeel.FMyFparentFhadFtoFbeFtransferredFtoFaFlong-termFcareFfacility."F-
FCorrectFAnswer:
"WouldFyouFlikeFitFifFweFdiscussedFtheFtransferFwithFyourFfamilyFmember?"
ThisFresponseFfacilitatesFtherapeuticFcommunicationFandFprovidesFgeneralFleadsFwhileFmaintain
ingFclientFconfidentiality.
IncorrectFAnswers:
"TheFtransferFofFyourFfamilyFmemberFisFbeingFdoneFbecauseFtheFproviderFknowsFwhat'sFbest."FT
hisFisFaFdefensiveFresponseFwhichFcanFhinderFfurtherFcommunication.
"WhyFareFyouFsoFconcernedFaboutFthisFtransfer?"
AskingFaFwhyFquestionFcanFmakeFtheFrecipientFdefensiveFwhichFcanFhinderFfurtherFcommunicat
ion.
"IFknowFhowFyouFfeel.FMyFparentFhadFtoFbeFtransferredFtoFaFlong-termFcareFfacility."
,ThisFisFaFsympatheticFresponse,FwhichFcanFinterfereFwithFaFtherapeuticFrelationship.
AFnurseFisFreviewingFtheFlaboratoryFresultsFofFaFfemaleFclientFwhoFhasFhypovolemia.FWhichFofFt
heFfollowingFlaboratoryFresultFwouldFbeFaFpriorityFforFtheFnurseFreportFtoFtheFprovider?
BUNF21Fmg/dLF(10FtoF20Fmg/dL)
CreatinineF1.4Fmg/dLF(0.5FtoF1.1Fmg/dL)
SodiumF132FmEq/LF(136FtoF145FmEq/L)
PotassiumF5.8FmEq/LF(3.5FtoF5FmEq/L)F-FCorrectFAnswer:
PotassiumF5.8FmEq/LF(3.5FtoF5FmEq/L)
WhenFusingFtheFurgentFversusFnonurgentFapproachFtoFclientFcare,FtheFnurseFshouldFdetermineFth
atFthisFpotassiumFlevelFisFaboveFtheFexpectedFreferenceFrangeFandFshouldFbeFreportedFtoFtheFprov
ider.FPotassiumFaffectsFtheFcontractilityFofFtheFheartFandFthisFclientFwouldFbeFatFriskFforFdevelop
ingFdysrhythmias.
IncorrectFanswers:
BUNF21Fmg/dLF(10FtoF20Fmg/dL)
ThisFBUNFlevelFisFslightlyFaboveFtheFexpectedFreferenceFrangeFandFisFanFexpectedFnon-
urgentFfindingFforFaFclientFwhoFhasFhypovolemia;Ftherefore,FthereFisFanotherFlaboratoryFresultFth
atFisFaFpriorityFforFtheFnurseFtoFreportFtoFtheFprovider.
CreatinineF1.4Fmg/dLF(0.5FtoF1.1Fmg/dL)
ThisFcreatinineFlevelFisFslightlyFaboveFtheFexpectedFreferenceFrangeFandFisFanFexpectedFnon-
FurgentFfindingFforFaFclientFwhoFhasFhypovolemia;Ftherefore,FthereFisFanotherFlaboratoryFresultFt
hatFisFaFaFpriorityFforFtheFnurseFtoFreportFtoFtheFprovider.
SodiumF132FmEq/LF(136FtoF145FmEq/L)
ThisFsodiumFlevelFisFslightlyFbelowFtheFexpectedFreferenceFrangeFandFisFanFexpectedFnon-
FurgentFfindingFforFaFclientFwhoFhasFhypovolemia;Ftherefore,FthereFisFanotherFlaboratoryFresultFt
hatFisFaFpriorityFforFtheFnurseFtoFreportFtoFtheFprovider.
AFnurseFisFcaringFforFaFclientFwhoFreportsFdifficultyFfallingFasleep.FWhichFofFtheFfollowingFreco
mmendationsFshouldFtheFnurseFmake?
"DrinkFaFcupFofFhotFcocoaFbeforeFbedtime."F"Maintai
nFaFconsistentFtimeFtoFwakeFupFeachFday."F"ExerciseF1
FhourFbeforeFgoingFtoFbed."
"WatchFaFtelevisionFprogramFinFbedFbeforeFgoingFtoFsleep."F-
FCorrectFAnswer:F"MaintainFaFconsistentFtimeFtoFwakeFupFeachFday."
TheFclientFshouldFmaintainFaFconsistentFtimeFforFwakingFupFandFgoingFtoFsleep.FThisFhelpsFtoF
establishFanFinternalFsenseFofFsleepFandFwakingFonFaFdailyFbasisFandFhelpsFtoFmaintainFitFoverFt
ime.FThisFwillFhelpFpromoteFsleepFforFtheFclient.
IncorrectFAnswers:
"DrinkFaFcupFofFhotFcocoaFbeforeFbedtime."
CocoaFcontainsFcaffeine,FwhichFisFaFstimulantFthatFcanFinterfereFwithFsleep.
"ExerciseF1FhourFbeforeFgoingFtoFbed."
ExercisingFwithinF2FhrFofFbedtimeFcanFinterfereFwithFsleep.
,"WatchFaFtelevisionFprogramFinFbedFbeforeFgoingFtoFsleep."
TheFclientFshouldFavoidFwatchingFtelevisionFinFbedFbeforeFgoingFtoFsleepFtoFreduceFstimulationF
inForderFtoFpromoteFrest.
AFnurseFonFaFmedical-
surgicalFunitFisFcaringFforFaFclientFwhoFhasFaFnewFprescriptionFforFwristFrestraints.FWhichFofFfoll
owingFactionsFshouldFtheFnurseFtake?
PadFtheFclient'sFwristFbeforeFapplyingFtheFrestraints.FEvaluat
eFtheFclient'sFcirculationFeveryF8FhrFafterFapplication.
RemoveFtheFrestraintsFeveryF4FhrFtoFevaluateFtheFclient'sFstatus.FSec
ureFtheFrestraintFtiesFtoFtheFbed'sFsideFrails.F-
FCorrectFAnswer:FPadFtheFclient'sFwristFbeforeFapplyingFtheFrestraint
s.
TheFuseFofFrestraintsFwithoutFpaddingFcanFabradeFtheFclient'sFskin,FresultingFinFclientFinjury.
IncorrectFAnswers:
EvaluateFtheFclient'sFcirculationFeveryF8FhrFafterFapplication.
TheFnurseFshouldFevaluateFtheFclient'sFcirculation,FrangeFofFmotion,FvitalFsigns,FandFoverallFstat
usFeveryF15FminFafterFinitialFapplicationFofFrestraints.
RemoveFtheFrestraintsFeveryF4FhrFtoFevaluateFtheFclient'sFstatus.
TheFnurseFshouldFremoveFtheFrestraintsFatFleastFeveryF2FhrFtoFrepositionFtheFclientFandFassessFne
edsFforFhygieneFandFtoileting.
SecureFtheFrestraintFtiesFtoFtheFbed'sFsideFrails.
TheFnurseFshouldFsecureFtheFrestraintFtiesFtoFaFpartFofFtheFbedFframeFthatFmovesFwithFtheFclientFt
oFreduceFtheFriskFofFinjury.
AFclientFwhoFisFnonambulatoryFnotifiesFtheFnurseFthatFtheirFtrashFcanFisFonFfire.FAfterFtheFnurseF
confirmsFtheFpresenceFofFtheFfire,FwhichFofFtheFfollowingFactionsFshouldFtheFnurseFtakeFnext?
ActivateFtheFemergencyFfireFalarm.FExtinguis
hFtheFfire.
EvacuateFtheFclient.
ConfineFtheFfire.F-FCorrectFAnswer:
EvacuateFtheFclient.
AccordingFtoFtheFRACEFmnemonic,FtheFfirstFactionFinFresponseFtoFaFfireFisFtoFrescueFtheF
clients,FmovingFthemFtoFaFsafeFarea.
IncorrectFAnswers:
ActivateFtheFemergencyFfireFalarm.
AccordingFtoFtheFRACEFmnemonic,FtheFsecondFactionFinFresponseFtoFaFfireFisFtoFactivateFtheFala
rm.
ExtinguishFtheFfire.
AccordingFtoFtheFRACEFmnemonic,FtheFfourthFactionFinFresponseFtoFaFfireFisFtoFattemptFtoFextin
guishFtheFfire.
ConfineFtheFfire.
, AccordingFtoFtheFRACEFmnemonic,FtheFthirdFactionFinFresponseFtoFaFfireFisFtoFcontainFtheFfireFb
yFclosingFallFtheFdoorsFandFwindowsFinFtheFarea.FTheFnurseFshouldFalsoFturnFoffFoxygenFandFele
ctricalFequipmentFinFtheFareaFofFtheFfire.
AFnurseFisFpreparingFtoFadministerF0.9%FsodiumFchlorideF750FmLFIVFtoFinfuseFoverF7Fhr.FTheFn
urseFshouldFsetFtheFinfusionFpumpFtoFdeliverFhowFmanyFmL/hr?F-F107FmL/hr
AFnurseFisFassessingFfourFadultFclients.FWhichFofFtheFfollowingFphysicalFassessmentFtech
niquesFshouldFtheFnurseFuse?
UseFtheFFace,FLegs,FActivity,FCry,FandFConsolabilityF(FLACC)FpainFratingFscaleFforFaFclientFwh
oFisFexperiencingFpain.
EnsureFtheFbladderFofFtheFbloodFpressureFcuffFsurroundsF80%FofFtheFclient'sFarm.
ObtainFanFapicalFheartFrateFbyFauscultatingFatFtheFthirdFintercostalFspaceFleftFofFtheFsternum.FPal
pateFtheFclient'sFabdomenFbeforeFauscultatingFbowelFsounds.F-FCorrectFAnswer:
EnsureFtheFbladderFofFtheFbloodFpressureFcuffFsurroundsF80%FofFtheFclient'sFarm.
TheFnurseFshouldFuseFaFbloodFpressureFcuffFwithFaFbladderFthatFsurroundsF80%FofFtheFclient'sFar
mFcircumferenceFtoFgiveFanFaccurateFreading.
IncorrectFAnswers:
UseFtheFFace,FLegs,FActivity,FCry,FandFConsolabilityF(FLACC)FpainFratingFscaleFforFaFclientFwh
oFisFexperiencingFpain.
TheFnurseFshouldFuseFanFage-appropriateFpain-
ratingFscale,FsuchFasFtheFvisualFanalogForFnumericalFscale,FwhenFassessingFtheFpainFlevelFofFanFa
dult.FTheFFLACCFpainFratingFscaleFisFusedFforFclientsFagedFfromF2FmonthsFtoF7FyearsFold.
ObtainFanFapicalFheartFrateFbyFauscultatingFatFtheFthirdFintercostalFspaceFleftFofFtheFsternum.FTh
eFnurseFshouldFplaceFtheFstethoscopeFatFtheFpointFofFmaximalFimpulse,FwhichFisFatFtheFfifthFinter
costalFspaceFatFtheFmidclavicularFlineFleftFofFtheFsternum.
PalpateFtheFclient'sFabdomenFbeforeFauscultatingFbowelFsounds.
WhenFassessingFanFadultFclient'sFabdomen,FtheFnurseFshouldFauscultateFbowelFsoundsFbeforeFpe
rformingFpalpationFinForderFnotFtoFchangeFtheFcharacterFofFtheFsounds.
AFnurseFisFcaringFforFaFclientFwhoFhasFaFterminalFdiagnosisFandFwhoseFhealthFisFdeclining.FTheF
clientFrequestsFinformationFaboutFadvanceFdirectives.FWhichFofFtheFfollowingFresponsesFshoul
dFtheFnurseFmake?
"WeFcanFtalkFaboutFadvanceFdirectives,FandFIFcanFalsoFgiveFyouFsomeFbrochuresFaboutFthem."F"
YouFshouldFsetFupFaFtimeFtoFtalkFwithFyourFproviderFaboutFthat."
"Let'sFdiscussFhowFyouFareFfeelingFtoday,FandFwe'llFsaveFtheFplanningFforFwhenFyouFareFfeelingF
aFlittleFbetter."
"WhyFdoFyouFwantFtoFdiscussFthisFwithoutFyourFpartnerFhereFtoFplanFthisFwithFyou?"F-
FCorrectFAnswer:
"WeFcanFtalkFaboutFadvanceFdirectives,FandFIFcanFalsoFgiveFyouFsomeFbrochuresFaboutFthem."F
WithFthisFstatement,FtheFnurseFoffersFtoFprovideFtheFinformationFtheFclientFneedsFinFaFdirectFan
dFsimpleFway.
IncorrectFAnswers:
"YouFshouldFsetFupFaFtimeFtoFtalkFwithFyourFproviderFaboutFthat."
A+ WITH CORRECT QUESTION AND ANSWERS
AFnurseFisFadministeringF1FLFofF0.9%FsodiumFchlorideFtoFaFclientFwhoFisFpostoperativeFandFhasF
fluidFvolumeFdeficit.FWhichFofFtheFfollowingFchangesFshouldFtheFnurseFidentifyFasFanFindicatio
nFthatFtheFtreatmentFwasFsuccessful?
IncreaseFinFhematocritFincreas
eFinFrespiratoryFrateFDecreaseFi
nFheartFrate
DecreaseFinFcapillaryFrefillFtimeF-FCorrectFAnswer:
DecreaseFinFheartFrate
FluidFvolumeFdeficitFcausesFtachycardia.FWithFcorrectionFofFtheFimbalance,FtheFheartFrateFshoul
dFreturnFtoFtheFexpectedFrange.
IncorrectFAnswers:
IncreaseFinFhematocrit:
FluidFvolumeFdeficitFcausesFanFincreaseFinFhematocritFlevelFdueFtoFdepletionFofFextracellularFflu
id.FWithFcorrectionFofFtheFimbalance,FtheFhematocritFlevelFshouldFdecrease.
increaseFinFrespiratoryFrate
FluidFvolumeFdeficitFcausesFanFincreaseFinFrespiratoryFrate.FWithFcorrectionFofFtheFimbalance,Ft
heFrespiratoryFrateFshouldFreturnFtoFtheFexpectedFrange.
DecreaseFinFcapillaryFrefillFtime
FluidFvolumeFdeficitFslowsFcapillaryFrefill.FWithFcorrectionFofFtheFimbalance,FcapillaryFrefillFti
meFshouldFreturnFtoFtheFexpectedFrange.
AFnurseFisFcaringFforFaFclientFwhoFisFscheduledFtoFbeFtransferredFtoFaFlong-
termFcareFfacility.FTheFclient'sFfamilyFquestionsFtheFnurseFaboutFtheFreasonsFforFtheFtransfer.FW
hichFofFtheFfollowingFresponsesFmadeFbyFtheFnurseFisFappropriate?
"TheFtransferFofFyourFfamilyFmemberFisFbeingFdoneFbecauseFtheFproviderFknowsFwhat'sFbest."F"
WouldFyouFlikeFitFifFweFdiscussedFtheFtransferFwithFyourFfamilyFmember?"
"WhyFareFyouFsoFconcernedFaboutFthisFtransfer?"
"IFknowFhowFyouFfeel.FMyFparentFhadFtoFbeFtransferredFtoFaFlong-termFcareFfacility."F-
FCorrectFAnswer:
"WouldFyouFlikeFitFifFweFdiscussedFtheFtransferFwithFyourFfamilyFmember?"
ThisFresponseFfacilitatesFtherapeuticFcommunicationFandFprovidesFgeneralFleadsFwhileFmaintain
ingFclientFconfidentiality.
IncorrectFAnswers:
"TheFtransferFofFyourFfamilyFmemberFisFbeingFdoneFbecauseFtheFproviderFknowsFwhat'sFbest."FT
hisFisFaFdefensiveFresponseFwhichFcanFhinderFfurtherFcommunication.
"WhyFareFyouFsoFconcernedFaboutFthisFtransfer?"
AskingFaFwhyFquestionFcanFmakeFtheFrecipientFdefensiveFwhichFcanFhinderFfurtherFcommunicat
ion.
"IFknowFhowFyouFfeel.FMyFparentFhadFtoFbeFtransferredFtoFaFlong-termFcareFfacility."
,ThisFisFaFsympatheticFresponse,FwhichFcanFinterfereFwithFaFtherapeuticFrelationship.
AFnurseFisFreviewingFtheFlaboratoryFresultsFofFaFfemaleFclientFwhoFhasFhypovolemia.FWhichFofFt
heFfollowingFlaboratoryFresultFwouldFbeFaFpriorityFforFtheFnurseFreportFtoFtheFprovider?
BUNF21Fmg/dLF(10FtoF20Fmg/dL)
CreatinineF1.4Fmg/dLF(0.5FtoF1.1Fmg/dL)
SodiumF132FmEq/LF(136FtoF145FmEq/L)
PotassiumF5.8FmEq/LF(3.5FtoF5FmEq/L)F-FCorrectFAnswer:
PotassiumF5.8FmEq/LF(3.5FtoF5FmEq/L)
WhenFusingFtheFurgentFversusFnonurgentFapproachFtoFclientFcare,FtheFnurseFshouldFdetermineFth
atFthisFpotassiumFlevelFisFaboveFtheFexpectedFreferenceFrangeFandFshouldFbeFreportedFtoFtheFprov
ider.FPotassiumFaffectsFtheFcontractilityFofFtheFheartFandFthisFclientFwouldFbeFatFriskFforFdevelop
ingFdysrhythmias.
IncorrectFanswers:
BUNF21Fmg/dLF(10FtoF20Fmg/dL)
ThisFBUNFlevelFisFslightlyFaboveFtheFexpectedFreferenceFrangeFandFisFanFexpectedFnon-
urgentFfindingFforFaFclientFwhoFhasFhypovolemia;Ftherefore,FthereFisFanotherFlaboratoryFresultFth
atFisFaFpriorityFforFtheFnurseFtoFreportFtoFtheFprovider.
CreatinineF1.4Fmg/dLF(0.5FtoF1.1Fmg/dL)
ThisFcreatinineFlevelFisFslightlyFaboveFtheFexpectedFreferenceFrangeFandFisFanFexpectedFnon-
FurgentFfindingFforFaFclientFwhoFhasFhypovolemia;Ftherefore,FthereFisFanotherFlaboratoryFresultFt
hatFisFaFaFpriorityFforFtheFnurseFtoFreportFtoFtheFprovider.
SodiumF132FmEq/LF(136FtoF145FmEq/L)
ThisFsodiumFlevelFisFslightlyFbelowFtheFexpectedFreferenceFrangeFandFisFanFexpectedFnon-
FurgentFfindingFforFaFclientFwhoFhasFhypovolemia;Ftherefore,FthereFisFanotherFlaboratoryFresultFt
hatFisFaFpriorityFforFtheFnurseFtoFreportFtoFtheFprovider.
AFnurseFisFcaringFforFaFclientFwhoFreportsFdifficultyFfallingFasleep.FWhichFofFtheFfollowingFreco
mmendationsFshouldFtheFnurseFmake?
"DrinkFaFcupFofFhotFcocoaFbeforeFbedtime."F"Maintai
nFaFconsistentFtimeFtoFwakeFupFeachFday."F"ExerciseF1
FhourFbeforeFgoingFtoFbed."
"WatchFaFtelevisionFprogramFinFbedFbeforeFgoingFtoFsleep."F-
FCorrectFAnswer:F"MaintainFaFconsistentFtimeFtoFwakeFupFeachFday."
TheFclientFshouldFmaintainFaFconsistentFtimeFforFwakingFupFandFgoingFtoFsleep.FThisFhelpsFtoF
establishFanFinternalFsenseFofFsleepFandFwakingFonFaFdailyFbasisFandFhelpsFtoFmaintainFitFoverFt
ime.FThisFwillFhelpFpromoteFsleepFforFtheFclient.
IncorrectFAnswers:
"DrinkFaFcupFofFhotFcocoaFbeforeFbedtime."
CocoaFcontainsFcaffeine,FwhichFisFaFstimulantFthatFcanFinterfereFwithFsleep.
"ExerciseF1FhourFbeforeFgoingFtoFbed."
ExercisingFwithinF2FhrFofFbedtimeFcanFinterfereFwithFsleep.
,"WatchFaFtelevisionFprogramFinFbedFbeforeFgoingFtoFsleep."
TheFclientFshouldFavoidFwatchingFtelevisionFinFbedFbeforeFgoingFtoFsleepFtoFreduceFstimulationF
inForderFtoFpromoteFrest.
AFnurseFonFaFmedical-
surgicalFunitFisFcaringFforFaFclientFwhoFhasFaFnewFprescriptionFforFwristFrestraints.FWhichFofFfoll
owingFactionsFshouldFtheFnurseFtake?
PadFtheFclient'sFwristFbeforeFapplyingFtheFrestraints.FEvaluat
eFtheFclient'sFcirculationFeveryF8FhrFafterFapplication.
RemoveFtheFrestraintsFeveryF4FhrFtoFevaluateFtheFclient'sFstatus.FSec
ureFtheFrestraintFtiesFtoFtheFbed'sFsideFrails.F-
FCorrectFAnswer:FPadFtheFclient'sFwristFbeforeFapplyingFtheFrestraint
s.
TheFuseFofFrestraintsFwithoutFpaddingFcanFabradeFtheFclient'sFskin,FresultingFinFclientFinjury.
IncorrectFAnswers:
EvaluateFtheFclient'sFcirculationFeveryF8FhrFafterFapplication.
TheFnurseFshouldFevaluateFtheFclient'sFcirculation,FrangeFofFmotion,FvitalFsigns,FandFoverallFstat
usFeveryF15FminFafterFinitialFapplicationFofFrestraints.
RemoveFtheFrestraintsFeveryF4FhrFtoFevaluateFtheFclient'sFstatus.
TheFnurseFshouldFremoveFtheFrestraintsFatFleastFeveryF2FhrFtoFrepositionFtheFclientFandFassessFne
edsFforFhygieneFandFtoileting.
SecureFtheFrestraintFtiesFtoFtheFbed'sFsideFrails.
TheFnurseFshouldFsecureFtheFrestraintFtiesFtoFaFpartFofFtheFbedFframeFthatFmovesFwithFtheFclientFt
oFreduceFtheFriskFofFinjury.
AFclientFwhoFisFnonambulatoryFnotifiesFtheFnurseFthatFtheirFtrashFcanFisFonFfire.FAfterFtheFnurseF
confirmsFtheFpresenceFofFtheFfire,FwhichFofFtheFfollowingFactionsFshouldFtheFnurseFtakeFnext?
ActivateFtheFemergencyFfireFalarm.FExtinguis
hFtheFfire.
EvacuateFtheFclient.
ConfineFtheFfire.F-FCorrectFAnswer:
EvacuateFtheFclient.
AccordingFtoFtheFRACEFmnemonic,FtheFfirstFactionFinFresponseFtoFaFfireFisFtoFrescueFtheF
clients,FmovingFthemFtoFaFsafeFarea.
IncorrectFAnswers:
ActivateFtheFemergencyFfireFalarm.
AccordingFtoFtheFRACEFmnemonic,FtheFsecondFactionFinFresponseFtoFaFfireFisFtoFactivateFtheFala
rm.
ExtinguishFtheFfire.
AccordingFtoFtheFRACEFmnemonic,FtheFfourthFactionFinFresponseFtoFaFfireFisFtoFattemptFtoFextin
guishFtheFfire.
ConfineFtheFfire.
, AccordingFtoFtheFRACEFmnemonic,FtheFthirdFactionFinFresponseFtoFaFfireFisFtoFcontainFtheFfireFb
yFclosingFallFtheFdoorsFandFwindowsFinFtheFarea.FTheFnurseFshouldFalsoFturnFoffFoxygenFandFele
ctricalFequipmentFinFtheFareaFofFtheFfire.
AFnurseFisFpreparingFtoFadministerF0.9%FsodiumFchlorideF750FmLFIVFtoFinfuseFoverF7Fhr.FTheFn
urseFshouldFsetFtheFinfusionFpumpFtoFdeliverFhowFmanyFmL/hr?F-F107FmL/hr
AFnurseFisFassessingFfourFadultFclients.FWhichFofFtheFfollowingFphysicalFassessmentFtech
niquesFshouldFtheFnurseFuse?
UseFtheFFace,FLegs,FActivity,FCry,FandFConsolabilityF(FLACC)FpainFratingFscaleFforFaFclientFwh
oFisFexperiencingFpain.
EnsureFtheFbladderFofFtheFbloodFpressureFcuffFsurroundsF80%FofFtheFclient'sFarm.
ObtainFanFapicalFheartFrateFbyFauscultatingFatFtheFthirdFintercostalFspaceFleftFofFtheFsternum.FPal
pateFtheFclient'sFabdomenFbeforeFauscultatingFbowelFsounds.F-FCorrectFAnswer:
EnsureFtheFbladderFofFtheFbloodFpressureFcuffFsurroundsF80%FofFtheFclient'sFarm.
TheFnurseFshouldFuseFaFbloodFpressureFcuffFwithFaFbladderFthatFsurroundsF80%FofFtheFclient'sFar
mFcircumferenceFtoFgiveFanFaccurateFreading.
IncorrectFAnswers:
UseFtheFFace,FLegs,FActivity,FCry,FandFConsolabilityF(FLACC)FpainFratingFscaleFforFaFclientFwh
oFisFexperiencingFpain.
TheFnurseFshouldFuseFanFage-appropriateFpain-
ratingFscale,FsuchFasFtheFvisualFanalogForFnumericalFscale,FwhenFassessingFtheFpainFlevelFofFanFa
dult.FTheFFLACCFpainFratingFscaleFisFusedFforFclientsFagedFfromF2FmonthsFtoF7FyearsFold.
ObtainFanFapicalFheartFrateFbyFauscultatingFatFtheFthirdFintercostalFspaceFleftFofFtheFsternum.FTh
eFnurseFshouldFplaceFtheFstethoscopeFatFtheFpointFofFmaximalFimpulse,FwhichFisFatFtheFfifthFinter
costalFspaceFatFtheFmidclavicularFlineFleftFofFtheFsternum.
PalpateFtheFclient'sFabdomenFbeforeFauscultatingFbowelFsounds.
WhenFassessingFanFadultFclient'sFabdomen,FtheFnurseFshouldFauscultateFbowelFsoundsFbeforeFpe
rformingFpalpationFinForderFnotFtoFchangeFtheFcharacterFofFtheFsounds.
AFnurseFisFcaringFforFaFclientFwhoFhasFaFterminalFdiagnosisFandFwhoseFhealthFisFdeclining.FTheF
clientFrequestsFinformationFaboutFadvanceFdirectives.FWhichFofFtheFfollowingFresponsesFshoul
dFtheFnurseFmake?
"WeFcanFtalkFaboutFadvanceFdirectives,FandFIFcanFalsoFgiveFyouFsomeFbrochuresFaboutFthem."F"
YouFshouldFsetFupFaFtimeFtoFtalkFwithFyourFproviderFaboutFthat."
"Let'sFdiscussFhowFyouFareFfeelingFtoday,FandFwe'llFsaveFtheFplanningFforFwhenFyouFareFfeelingF
aFlittleFbetter."
"WhyFdoFyouFwantFtoFdiscussFthisFwithoutFyourFpartnerFhereFtoFplanFthisFwithFyou?"F-
FCorrectFAnswer:
"WeFcanFtalkFaboutFadvanceFdirectives,FandFIFcanFalsoFgiveFyouFsomeFbrochuresFaboutFthem."F
WithFthisFstatement,FtheFnurseFoffersFtoFprovideFtheFinformationFtheFclientFneedsFinFaFdirectFan
dFsimpleFway.
IncorrectFAnswers:
"YouFshouldFsetFupFaFtimeFtoFtalkFwithFyourFproviderFaboutFthat."
