ATI RN Fundamentals Online Practice 2019 A with NGN

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? 1. Protective environment 2. Airborne precautions 3. Droplet precautions 4. Contact precautions Contact precautions Clients who have a compromised immune system require a ___ . protective environment ___ are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. Airborne precautions ___ are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. Droplet precautions Major wound infections require ___ , which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. contact precautions A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer 2. Focus teaching on what the client will need to do in the future to manage his illness 3. Provide the client with written information about the phases of loss and grief. 4. Reassure the client that this is an expected response to grief. Reassure the client that this is an expected response to grief. During the ___ of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. anger stage A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? 1. Assist the client into a prone position. 2. Place a sleeve over the top of each leg with the opening at the knee. 3. Make sure two fingers can fit under the sleeves. 4. Set the ankle pressure at 65 mm Hg. Make sure two fingers can fit under the sleeves. Caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves (notes) - Place client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves - Place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure - Ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate - Set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nursing use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid Hydrocolloid ___ dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. It forms a soft gel when it comes in contact with drainage. Alginate Moistened ___ promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Gauze ___ dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. Transparent ___ dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Hydrocolloid A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? 1. Advocacy ensures clients' safety, health, and rights. 2. Advocacy ensures that nurses are able to explain their own actions. 3. Advocacy ensures that nurses follow through on their promises to clients. 4. Advocacy ensures fairness in client care delivery and use of resources. Advocacy ensures clients' safety, health, and rights. ___ is a key component of professional nurses' code of ethics. The nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. Advocacy ___ is the responsibility of nurses to explain their own actions to their clients and employer. Accountability ___ is an agreement by nurses to follow through with promises made to clients. Fidelity ___ is fairness in client care delivery, including the distribution of resources and care. Justice A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1. Verify the client's name on their identification bracelet with the medication administration record. 2. Call the pharmacy to determine whether the client's medications are available. 3. Compare the client's home medications with the provider's prescriptions. 4. Place the client's home medication bottles in a secure location. Compare the client's home medications with the provider's prescriptions. ___ is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. Medication reconciliation The nurse should verify the client's ___ when administering medication name on their identification bracelet The nurse should call the ___ if the client's medications are not available to administer at the appropriate time pharmacy The nurse should compare the client's home medications with the provider's prescriptions when performing ___. medication reconciliation A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? - Pupil clarity - Visual fields - Visual acuity Lacrimal apparatus is - tear system - a group of glands, sacs and ducts that makes new tears and drains old ones away - lubricates and protects eyes Cloudy pupils mean that the client has ... - cataracts - vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly Testing visual field - use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. - clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall Assess visual acuity by using - Snellen chart to assess distance vision and a handheld card to assess near vision - Clients who wear eyeglasses should wear them during the assessments. - Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L ... BUN expected reference range 10 to 20 mg/dL Creatinine expected reference range 0.5 to 1.1 mg/dL for women 41 to 60 years of age 0.6 to 1.3 mg/dL for men 41 to 60 years of age Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine