ATI Fundamentals Proctored Exam

1. what are the health care regulatory agencies - joint commission state boards of nursing food and drug administration 2. what would be included in a plan of care for a patient with pertussis - wear a mask when providing care within 3ft of the client place a surgical mask on the client if being transported to another unit wear a gown when performing care that involves secretions 3. a client reports severe sore throat, pain when swallowing and swollen lymph nodes. what stage of infection is this - illness what are clinical manifestations of localized versus a systemic infection - fever malaise increase in pulse and respiratory rate 4. what actions should be taken to reduce risk of falls - call light in reach provide nonskid footwear complete fall risk assessment 5. what are actions for a patient who has had a seizure - place patient on side administer meds as prescribed be prepared to insert airway do not leave client alone during a seizure 6. what is the priority action for a client with a history of falls - complete a fall risk assessment 7. what are interventions for seclusion and restraints - assess restraints every 2 hours assess food, fluids, comfort, and safety and document every 15-30 mins 8. what should be included in a teaching about carbon monoxide poisoning - carbon monoxide binds with hemoglobin in the body 9. a client who has a heat stroke will have what - hypotension 10. who is at risk for complications from food poisoning - immunocompromised individuals 11. clients as risk for food poisoning are instructed to eat and drink what - only pasteurized milk, yogurt, cheese and other dairy products 12. what bed position should the bed be in for a client receiving eternal tube feeding due to dysphagia - semi-fowlers 13. a client asks to move from the bed to the chair what is the priority action - assess the clients ability to help with the transfer 14. 21 year old with a sore throat tells doctor he has not seen the doctor since highschool. what screening should be done - testicular exam 15. what should be included in health promotion and primary prevention for a school-aged child - child obesity substance use disorder scoliosis stranger awareness 16. what is the first sign of maturation in boys - enlargement of the testes and the scrotum 17. what are expected decreases in physical function of a middle age adult - metabolism gastric secretion glomerular function 18. what should be asked for a older adult who loses weight – do you eat alone or with someone have you started any new meds what have you eaten in the last 24 hour are you on a fixed income 19. what nutritional interventions are recommended for older adults - increase calcium and fiber decrease sodium 20. a client who is on bed rest should do what to maintain latency of airways - use incentive spirometer 21. what interventions should be used to reduce the risk of a dvt for a patient post-op - apply elastic stockings change position frequently 22. what are effects of immobility of the cardio vascular system - orthostatic hypotension stasis of blood in legs increased risk of thrombus less fluid volume in circulatory system diminished autonomic response increased oxygen requirements decreased cardiac output, poor cardiac effectiveness, increased cardiac workload 23. what are the immomobility effects of respiratory system - decreased respiratory movement, decreased oxygen and carbon monoxide exchange stasis of secretions and decreased and weekend respiratory muscles, atelectasis and hypostatic pneumonia 24. a 82 year old client in ER has temp of 101, pulse 114, respiration of 22. he is restless and skin is warm.. what actions are appropriate? - obtain culture specimen before initiating antimicrobials encourage rest assist with oral hygiene frequently increase fluids 25. what findings of a skin assessment require immediate intervention - cyanosis 26. what characteristics should be included when explaining rapid eye movement REM sleep - provides cognitive restoration it is difficult to awake a person vivid dreams are common 27. whole grain such as barley and oats, raw veggies, cabbage, legumes, lentils, black beans are - high in fiber 28. side effects of opioids - urinary retention, postural hypotension, pruritus, nausea, vomiting and respiratory depression 29. what are appropriate actions when initiating a bladder training program - have the client record voting times graduate increase the voiding intervals remind the client to hold urine until next scheduled time 30. what are clinical manifestations of infiltration - temperature around the IV site is cooler The IV dressing is damp the tissue around the venipuncture site is swollen 31. what are clinical manifestations fluid overload - distended neck veins increased blood pressure tachycardia shortness of breath crackles in the lungs edema 32. what is the highest priority assessment before performing in enteral feeding to a client with an NG tube - verify the placement of the tube 33. what are appropriate actions administering enteral feeding via NG tube in a long-term care facility - auscultate bowel sounds assist the client an upright position test the pH of gastric aspirate 34. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? - "I flushed what I urinated at 7:00 a.m. and have saved all urine since." 35. A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? - Calf Swelling 36. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? - A nurse asks a nurse from another unit to assist with her documentation. 37. A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? - Remove the stockings at least once per shift. 38. 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 39. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? - "You should have a fecal occult blood test every year." 40. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? - Place the client in a room with negativepressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene. 41. 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? - Have family members wear a gown and gloves when visiting. 42. A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? - Wrap monitoring cords with stockinette and tape them in place. 43. A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend? - Use progressive relaxation techniques at bedtime. 44. 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. – Air into NPH Air into Regular Draw up Regular Draw up NPH 45. 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.