ATI FUNDAMENTALS PROCTORED REAL EXAM ONLINE 2019 WITH NGN UPDATED COMPRESSED

ATI FUNDAMENTALS PROCTORED REAL EXAM ONLINE 2019 WITH NGN UPDATED COMPRESSED Question1loaderationalsprovided A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dres sing should the nurse use? Alginate INCORRECT Gauze INCORRECT Transparent INCORRECT Question: 1 of 60 CORRECT Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. RN Fundamental s Online Practice 2019 A with NGN CLOSE Question2loaderationalsprovided Time Elapsed: 00:02:07 Pause Remaining: 08:20:00 A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? "I am not worried because I still have hope that he will be okay." INCORRECT "I am relying on support from our family during this time." CORRECT "We can plan our family reunion once he recovers and comes home." INCORRECT "We don't see any reason to start discussing funeral arrangements right now." INCORRECT Question: 2 of 60 CORRECT This statement reflects false hope and possible denial of the terminal nature of the client's illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety. This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis. This statement reflects false hope and possibly denial of the terminal nature of the client's illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety. This statement reflects potentialfalse hope about and possible denial of the terminal nature of the client's illness. It also indicates the partner's potential inability or unwillingness to address unpleasant or challenging issues related to the client's death. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question3loaderationalsprovided Time Elapsed: 00:02:50 Pause Remaining: 08:20:00 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? (Select all that apply.) Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visualfields Visual acuity CORRECT Lacrimal apparatus is incorrect.If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk forfalls because clients cannot see items in their path clearly. Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety. Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visualfield to determine when the client sees the finger. Clients who have a visualfield 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. Visual acuity is correct. The nurse should use a 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. Question: 3 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question4loaderationalsprovided Time Elapsed: 00:06:15 Pause Remaining: 08:20:00 A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. INCORRECT When walking, the client moves the cane 46 cm (18 in) forward. INCORRECT The client holds the cane on the stronger side of her body. CORRECT The client moves her stronger limb forward with the cane. INCORRECT Question: 4 of 60 CORRECT The top of the cane should be parallel to the client's greater trochanter. To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. The client should hold the cane on the stronger side of her body to increase support and maintain alignment. The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question5loaderationalsprovided Time Elapsed: 00:11:06 Pause Remaining: 08:20:00 A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client's room has at least six air exchanges per hour. INCORRECT Make sure the client wears a mask when outside her room if there is construction in the area. CORRECT Place the client in a private room with negative-pressure airflow. INCORRECT Wear an N95 respirator when giving the client direct care. INCORRECT Question: 5 of 60 CORRECT A protective environment requires at least 12 air exchanges per hour. An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. The nurse should place the client in a private room that provides positive-pressure airflow. The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question6loaderationalsprovided Time Elapsed: 00:11:40 Pause Remaining: 08:20:00 A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? "I can place an extension cord across my living room to plug in my television." INCORRECT "I will hire someone to trim the tree that hangs low over the stairs of my front porch." CORRECT "I will place my alarm clock on my bedroom dresser across the room." INCORRECT "I will replace the old throw rug in my kitchen with a new one." INCORRECT Question: 6 of 60 CORRECT Extension cords should be securely fastened to the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping. Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk forfalls. Frequently used items like an alarm clock, glasses, or disposable tissues should be placed within reach, such as on the client's night stand. This helps to prevent the client from needing to get up and potentially falling in the night. Using throw rugs increases the client's risk for falls because they create a tripping and slipping hazard for the client. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question7loaderationalsprovided Time Elapsed: 00:12:36 Pause Remaining: 08:20:00 A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45° angle. CORRECT Administer the medication into the client's nondominant arm. INCORRECT Pull the client's skin laterally or downward prior to administration. INCORRECT Massage the injection site after administration. INCORRECT Question: 7 of 60 CORRECT The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. The nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. The nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Q uestion 8loade rationals provi de Time Elapsed: 00:13:17 Pause Remaining: 08:20:00 A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Use the complete name of the medication magnesium sulfate." CORRECT "Delete the space between the numerical dose and the unit of measure." INCORRECT "Write the letter U when noting the dosage of insulin." INCORRECT "Use the abbreviation SC when indicating an injection." INCORRECT Question: 8 of 60 CORRECT The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. The Institute for Safe Medication Practices recommends including a space between the dose and the unit of measure, such as in 10 mg, to avoidconfusion whendocumenting medication dosages. The Institute for Safe Medication Practices designates "unit(s)" as the correct term for use in medication documentation. The Institute for Safe Medication Practices designates either "subcut" or "subcutaneously" as the correct terms for use in medication documentation. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question9loaderationalsprovided Time Elapsed: 00:14:54 Pause Remaining: 08:20:00 A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity INCORRECT Sick role INCORRECT Role overload CORRECT Role conflict INCORRECT Question: 9 of 60 CORRECT Role ambiguity occurs when people are unclear about the expectations of their role in a given situation. Sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver. The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage. Role conflict develops when a person must assume multiple roles that have opposing expectations. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question10loaderationalsprovi de Time Elapsed: 00:15:36 Pause Remaining: 08:20:00 A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? Advocacy ensures clients' safety, health, and rights. CORRECT Advocacy ensures that nurses are able to explain their own actions. INCORRECT Advocacy ensures that nurses follow through on their promises to clients. INCORRECT Advocacy ensures fairness in client care delivery and use of resources. INCORRECT Question: 10 of 60 CORRECT Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights,including the rightto privacy, confidentiality, and refusalof care. Accountability, not advocacy, is the responsibility of nurses to explain their own actions to their clients and employer. Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients. Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question1loaderationalsprovi de Time Elapsed: 00:16:56 Pause Remaining: 08:20:00 A nurse is caring for a client who has a new diagnosis of seizure disorder. Complete the following sentence by using the list of options. Exhibit 1 Exhibit 2 Medication Administration Record The nurse should first address the client's physical safety followed by the client's positioning . Carbam azepine ER 200 mg PO twice per day Lorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min CORRECT My Answer Drop Down 1: Blood pressure is incorrect. The nurse should take the client'svital signs, but not while the seizure is in progress. Vital signs should be collected following the seizure. Physical safety is correct. The greatest risk to the client is injury from the seizure. Therefore, the first action the nurse should take is to ensure the client's physical safety by protecting the client's head. The nurse should cradle the client's head in their lap or placea pad underneath the head. Privacy is incorrect. The nurse should protect the client's privacyto the extent that they are able, but this is not the first action the nurse should take. Drop Down 2: PRN medication is incorrect. The nurse should stay with the client for the duration of the seizure to ensure their safety. The nurse should send another nurse to obtain the PRN medication. Positioning is correct. The nurse should attempt to turn the clienton their side with their head tilted slightly forward. This position will protect the client's airway from the aspiration of any secretionsthat may occur. Therefore, this is the second action the nurse should take. Incontinence is incorrect. The nurse should address any incontinence that occurs during the seizure, but this should be done after the seizing is over and the client's safety is ensured. Question: 11 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question12loaderationalsprovi de Time Elapsed: 00:19:03 Pause Remaining: 08:20:00 A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. INCORRECT Remove the NG tube ifthe client begins to gag or choke. INCORRECT Apply suction to the NG tube prior to insertion. INCORRECT Have the client take sips of water to promote insertion of the NG tube into the esophagus. CORRECT Question: 12 of 60 CORRECT The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration. The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk ofinjury to the client. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question13loaderationalsprovi de Time Elapsed: 00:19:30 Pause Remaining: 08:20:00 A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? Verify the client's name on their identification bracelet with the medication administration record. INCORRECT Call the pharmacy to determine whether the client's medications are available. INCORRECT Compare the client's home medications with the provider's prescriptions. CORRECT Place the client's home medication bottles in a secure location. INCORRECT Question: 13 of 60 CORRECT The nurse should verify the client's name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation. The nurse should call the pharmacy if the client's medications are not available to administer at the appropriate time; however,this action is not a part of performing medication reconciliation. The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation. The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Q uestion 14l oaded rational s provide Time Elapsed: 00:19:57 Pause Remaining: 08:20:00 A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? Insert the needle at a 15° angle. INCORRECT Aspirate for blood return prior to administration. INCORRECT Administer the medication into the abdomen. CORRECT Massage the site following the injection. INCORRECT Question: 14 of 60 CORRECT The nurse should instruct the client to insert the needle at a 45° to 90° angle to administer the medication into the subcutaneous tissue. The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question15loaderationalsprovi de Time Elapsed: 00:20:41 Pause Remaining: 08:20:00 A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process CORRECT As soon as the client's condition is stable INCORRECT During the initialteam conference INCORRECT After consulting with the client's family INCORRECT Question: 15 of 60 CORRECT Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability. Team conferences facilitate discharge planning, but they are not essentialfor initiating the planning process. The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question16loaderationalsprovi de Time Elapsed: 00:21:23 Pause Remaining: 08:20:00 A nurse is caring for a client who is receiving a unit of packed RBCs. Complete the following sentence by using the list of options. Exhibit 1 Exhibit 2 The client has manifestations of allergic reaction as evidenced by the client's itching . Nurses' Notes 0800: Packed RBCs initiated by the charge nurse through an18- guage peripheral IV to infuse over 2 hr. 0815: Client reports itching and anxiety. Client's face is flushed and has hives. CORRECT My Answer Drop Down 1: Allergic reaction is correct. The nurse should identify the client has manifestations of an allergic reaction as evidenced by itching,flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the provider. Febrile reaction is incorrect. A febrile reaction has manifestationsof fever, chills, headache, flushing of the face, and muscle pain. Fluid overload is incorrect. Fluid overload has manifestations ofcough, crackles heard in bases of the client's lungs, shortness of breath, and distended neck veins. Drop Down 2: Itching is correct. The nurse should identify that itching, flushingof the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider. Temperature is incorrect. The client's temperature is within theexpected reference range. An increase in temperature is a manifestation of febrile or hemolytic reaction to blood administration. Oxygen saturation is incorrect. The client's oxygen saturation iswithin the expected reference range. Question: 16 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question17loaderationalsprovi de Time Elapsed: 00:22:10 Pause Remaining: 08:20:00 A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? BUN 15 mg/dL INCORRECT Creatinine 0.8 mg/dL INCORRECT Sodium 143 mEq/L INCORRECT Potassium 5.4 mEq/L CORRECT Question: 17 of 60 CORRECT This value is within the expected reference range of 10 to 20 mg/dL. This value is within the expected reference range of 0.5 to 1.1 mg/dL for women 41 to 60 years of age and 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. This value is within the expected reference range of 136 to 145 mEq/L. This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question18loaderationalsprovi de Time Elapsed: 00:22:53 Pause Remaining: 08:20:00 A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? Remove the outer cannula cautiously for routine cleaning. INCORRECT Use tracheostomy covers when outdoors. CORRECT Use sterile technique when performing tracheostomy care at home. INCORRECT Cleanse irritated skin with full-strength hydrogen peroxide. INCORRECT Question: 18 of 60 CORRECT The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning. Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. In the home environment, medical asepsis with clean technique is appropriate. Hydrogen peroxide can irritate the skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent furtherirritation. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Q uestion 19l oaded rational s provide Time Elapsed: 00:23:32 Pause Remaining: 08:20:00 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? Protective environment INCORRECT Airborne precautions INCORRECT Droplet precautions INCORRECT Contact precautions CORRECT Question: 19 of 60 CORRECT Clients who have a compromised immune system require a protective environment. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns indiameter, includingtuberculosisandmeasles. Droplet 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. Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers shouldweara gownand gloves duringdirect contact withthis client. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE 14 Question20loaderationalsprovi de Time Elapsed: 00:24:13 Pause Remaining: 08:20:00 A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.) Crackles INCORRECT Rhonchi INCORRECT Friction rub INCORRECT Normal breath sounds CORRECT Question: 20 of 60 CORRECT 0: / 0:14 Unlike these breath sounds, crackles (also called rales) are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways. Rhonchi are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions. Friction rub is a scratching or squeaking sound that persists throughout the respiratory cycle. These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question21loaderationalsprovi de Time Elapsed: 00:25:37 Pause Remaining: 08:20:00 A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? Bend at the waist. INCORRECT Keep his feet close together. INCORRECT Use his back muscles for lifting. INCORRECT Stand close to the cabinet when lifting it. CORRECT Question: 21 of 60 CORRECT The nurse should bend the knees when lifting the cabinet. The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting the cabinet. The nurse should use the arm and leg muscles when lifting the cabinet because they are generally stronger than back muscles. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question2loaderationalsprovi de Time Elapsed: 00:26:50 Pause Remaining: 08:20:00 A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? Pad the client's wrist before applying the restraints. CORRECT Evaluate the client's circulation every 8 hr after application. INCORRECT Remove the restraints every 4 hr to evaluate the client's status. INCORRECT Secure the restraint ties to the bed's side rails. INCORRECT Question: 22 of 60 CORRECT The use of restraints without padding can abrade the client's skin, resulting in client injury. The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application ofrestraints. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Q uestion 23l oaded rational s provide Time Elapsed: 00:27:23 Pause Remaining: 08:20:00 A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries. CORRECT Move hazardous objects away from the client. INCORRECT Notify the provider. INCORRECT Ask the client to describe how she felt prior to the fall. INCORRECT Question: 23 of 60 CORRECT The first action the nurse should take when using the nursing process is to assess the client for injuries. Moving hazardous objects away from the client can prevent further injury; however, there is another action the nurse should take first. The nurse should notify the provider of the client's fall; however, there is another action the nurse should take first. Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse shouldtake first. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question24loaderationalsprovi de Time Elapsed: 00:28:00 Pause Remaining: 08:20:00 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? Assist the client into a prone position. INCORRECT Place a sleeve over the top of each leg with the opening at the knee. INCORRECT Make sure two fingers can fit under the sleeves. CORRECT Set the ankle pressure at 65 mm Hg. INCORRECT Question: 24 of 60 CORRECT The nurse should place the client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves. The nurse should 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. The nurse should 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. The nurse should 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. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question25loaderationalsprovi de Time Elapsed: 00:29:09 Pause Remaining: 08:20:00 A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel(AP). Exhibit 1 Exhibit 2 Exhibit 3 Prescriptions 1100: • CT of abdomen • NG tube to low wall suction • Serum amylase level Document the client's vital signs. Measure the client's intake and output. Transfer the client from wheelchair to bed. Insert an NG tube for the client. Collect data about the client's pain level. CORRECT My Answer Document the client's vital signs is correct. The nurse should identify that documenting the client's vital signs is a task that is within the AP's range of function. Measure the client's intake and output is correct. The nurse should identify that measuring the client's intake and output is atask that is within the AP's range of function. Transfer the client from wheelchair to bed is correct. The nurseshould identify that transferring the client from wheelchair to bed is a task that is within the AP's range of function. Insert an NG tube for the client is incorrect. Inserting an NG tube requires knowledge that is outside the range of function foran AP and should be performed by a nurse. Collect data about the client's pain level is incorrect. Collecting data about the client's pain level requires knowledge that is outsidethe range of function of an AP and should be performed by a nurse. Question: 25 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question26loaderationalsprovi de Time Elapsed: 00:30:00 Pause Remaining: 08:20:00 A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? Examine personal values about the issue. CORRECT Tell the parents that this is a necessary procedure. INCORRECT Inform the parents that the staff does not require their consent. INCORRECT Contact a spiritual support person to explain the importance of the procedure. INCORRECT Question: 26 of 60 CORRECT Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. The nurse should provide the parents with information about the procedure. However, telling the parents that this is a necessary procedure disregards the parents' religious beliefs and their right to refuse treatments. Parents must give consent for a child to receive a blood transfusion. The nurse or the provider should provide information about the procedure. Spiritual support people attend to clients' and families' spiritual needs, not their physiological needs. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question27loaderationalsprovi de Time Elapsed: 00:31:02 Pause Remaining: 08:20:00 A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? Document the provider's statement in the medical record. INCORRECT Complete an incident report. INCORRECT Consult the facility's risk manager. INCORRECT Notify the nursing manager. CORRECT Question: 27 of 60 CORRECT The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question28loaderationalsprovi de Time Elapsed: 00:31:57 Pause Remaining: 08:20:00 A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? Turn the client every 2 hr. CORRECT Administer an antiemetic every 6 hr. INCORRECT Hold oral care. INCORRECT Increase the room's temperature. INCORRECT Question: 28 of 60 CORRECT The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations. The nurse should administer antiemetics for clients who are experiencing nausea or vomiting. However, this is not the correct action to take when assisting a client who is experiencing respiratory difficulty at the end of life. The nurse should provide frequent oral care in order to keep the client's mouth moist and provide comfort. Keeping the airtemperature cool by allowing air to circulate with the use of a fan or opening windows is more comfortable for a client who is dying and will decrease air hunger. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question29loaderationalsprovi de Time Elapsed: 00:32:41 Pause Remaining: 08:20:00 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? Discuss the risk factors for colon cancer. INCORRECT Focus teaching on what the client will need to do in the future to manage his illness. INCORRECT Provide the client with written information about the phases of loss and grief. INCORRECT Reassure the client that this is an expected response to grief. CORRECT Question: 29 of 60 CORRECT The client might perceive this as challenging or argumentative and react defensively. Instead, the nurse should listen to the client's concerns and should avoid challenging him. During the anger stage of the client's psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face the future. Unless the client requests reading materials about loss, this is not an optimaltime to provide them. At this stage, the client needs to express his feelings without any expectations for learning. During the anger stage 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. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question30loaderationalsprovi de Time Elapsed: 00:33:10 Pause Remaining: 08:20:00 A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A lesion with uniform pigmentation INCORRECT New appearance of petechiae INCORRECT A mole with an asymmetrical appearance CORRECT The presence of a papule INCORRECT Question: 30 of 60 CORRECT Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks differentfrom the other part. Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of a skin malignancy. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question31loaderationalsprovi de Time Elapsed: 00:33:33 Pause Remaining: 08:20:00 A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? Biofeedback INCORRECT Aloe INCORRECT Feverfew INCORRECT Acupuncture CORRECT Question: 31 of 60 CORRECT Biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique. Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy. Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy. The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk offurther infection. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question32loaderationalsprovi de Time Elapsed: 00:35:13 Pause Remaining: 08:20:00 A nurse in an emergency department is caring for a client. Complete the following sentence by using the list of options. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Physical Examination The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe . 1200: Influenza with nausea, vomiting, and diarrhea for 3days. Client istachycardic, hypotensive, and tachypneic, withweak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids. CORRECT My Answer Drop Down 1: Review medications that might be causing confusion is correct. Using the nursing process, the first step the nurse shouldtake is to assess for a cause of the client's confusion. Obtain a prescription from the provider for restraints is incorrect. The nurse should first assess for a cause of the client's confusion, followed by using alternative methods to protect the client from injury. Assess where the restraint will be placed on the client is incorrect. The nurse should first assess for a cause of the client's confusion, followed by using alternative methods to protect the client from injury. Drop Down 2: Padding bony prominences under the restraint is incorrect. If assessing for a cause and attempting alternative methods to keepthe client safe is not effective, the nurse must first obtain a prescription from the provider before applying the restraint. Monitoring the client in restraints every 2 hr is incorrect. If assessing for a cause and attempting alternative methods to keepthe client safe is not effective, the nurse must first obtain a prescription from the provider before applying the restraint. Using other methods to keep the client safe is correct. After assessing for the cause of the client's confusion, the nurse shouldattempt alternatives to the use of restraints, such as covering the client's IV lines or asking a family member to stay with the client. The use of restraints should be avoided if possible. Question: 32 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question3loaderationalsprovi de Time Elapsed: 00:35:53 Pause Remaining: 08:20:00 A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? "You would have so much more time to spend with your family." INCORRECT "You should consider getting a part-time job or doing volunteer work." INCORRECT "Let's talk about how the change in your job status will affect you." CORRECT "Why wouldn't you want to retire and relax?" INCORRECT Question: 33 of 60 CORRECT This response is nontherapeutic because the nurse is minimizing the client's feelings and making assumptions about the client's relationships. This response is nontherapeutic because the nurse is minimizing the client's feelings and offering personal advice. This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement. This response is nontherapeutic because the nurse is asking a "why" question, which can provoke a defensive response from the client. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question34loaderationalsprovi de Time Elapsed: 00:37:17 Pause Remaining: 08:20:00 A nurse is admitting a client to a health care facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Exhibit 1 Exhibit 2 Exhibit 3 Select all that apply. Diagnostic Results 1400: Chest x-ray positive for inflammation and infiltrates inupper lobes QuantiFERON-TB positive (negative) Tuberculosis culture positive (negative) Wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room. Place the client in a negative airflow room. Remove mask after exiting the client's room. Wear a sterile, water-resistant gown if within 3 feet of the client. CORRECT My Answer Question: 34 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 maskwhen caring for the client. Place a container for soiled linens inside the client's room iscorrect. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a clientwho is in airborne precautions for tuberculosis to prevent exposure to the infection. Wear a sterile, water-resi stant gown if within 3 feet of the client is incorrect. The nurse should identify that the client has tuberculosis, which requires airborne precautions. Sterile gowns are not indicated when caring for a client who is in airborne precautions. Water-resistant gowns are only indicated if there is alikelihood of contact with the client's body fluids. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question35loaderationalsprovi de Time Elapsed: 00:38:01 Pause Remaining: 08:20:00 A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? Request that a respiratory therapist discuss the technique for incentive spirometry with the client. INCORRECT Determine the reasons why the client is refusing to use the incentive spirometer. CORRECT Document the client's refusalto participate in health restorative activities. INCORRECT Administer a pain medication to the client. INCORRECT Question: 35 of 60 CORRECT The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. If other interventions to promote the client's use of the incentive spirometer are unsuccessful, the nurse must document the client's refusal; however, this is not the priority action for the nurse to take. Pain or incisional complications might make the client refuse spirometry; however, administering medication is not the priority action for the nurse to take. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question36loaderationalsprovi de Time Elapsed: 00:38:33 Pause Remaining: 08:20:00 A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? Combine client care tasks when caring for multiple clients. INCORRECT Wait untilthe end of the shift to document client care. INCORRECT Use the planning step of the nursing process to prioritize client care delivery. CORRECT Allow for interruptions in tasks to discuss client care issues with colleagues. INCORRECT Question: 36 of 60 CORRECT The nurse should complete the tasks for one client before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors. Documentation should be completed in a timely manner after care is performed to reduce errors and unsafe client care. Performing documentation at the end of the shift is not effective time management. Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. An important principle of time management is controlling interruptions to reduce errors and loss of care delivery time. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question37loaderationalsprovi de Time Elapsed: 00:38:58 Pause Remaining: 08:20:00 A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurseidentify as indicating the correct technique for eliciting the client's patellar reflex? INCORRECT CORRECT Question: 37 of 60 CORRECT The nurse should identify this image as assessing the client's Achilles reflex. To elicit the expected response of plantar flexion of the foot, the nurse should bend the client's ankle slightly backward and tap the Achilles tendon at the ankle just above the heel using a reflex hammer. RN Fundamental s Online Practice 2019 A with NGN CLOSE The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer. RN Fundamental s Online Practice 2019 A with NGN CLOSE INCORRECT INCORRECT The nurse should identify this image as assessing the client's biceps reflex. To elicit the expected response of arm flexion at the elbow, the nurse should bend the client's arm at the elbow with palms down and tap the biceps tendon using a reflex hammer. The nurse should identify this image as assessing the client's triceps reflex. To elicit the expected response of arm extension at the elbow, the nurse should hold the client's upper arm horizontally while allowing the lower part of the client's arm to relax and tap the triceps tendon just above the elbow using a reflex hammer. RN Fundamental s Online Practice 2019 A with NGN CLOSE Question38loaderationalsprovi de Time Elapsed: 00:40:20 Pause Remaining: 08:20:00 A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which thenurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) CORRECT Question: 38 of 60 CORRECT Obtain the pronouncement of death from the provider. Remove tubes and indwelling lines. Wash the client's body. Ask the client's family members if they would like to viewthe body. Place a name tag on the body. The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question 39 loaded rationals provided Time Elapsed: 00:41:00 Pause Remaining: 08:20:00 A nurse is caring for a client who has COPD. Select the 3 findings that require follow-up. Exhibit 1 Exhibit 2 Exhibit 3 Vital Signs 1000: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/min Respirations 32/min Oxygen saturation 85% on room air Breath sounds Blood pressure Oxygen saturation Temperature Heart rate CORRECT My Answer Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not require follow-up by the nurse. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicatin g hypoxia, and requires follow-up by the nurse. Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse. Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to 100/min and does not require follow-up by the nurse. Question: 39 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question40loaderationalsprovi de Time Elapsed: 00:41:53 Pause Remaining: 08:20:00 A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? "I think I should take my pain medication more often, since it is not controlling my pain." INCORRECT "Breathing faster will help me keep my mind off of the pain." INCORRECT "It might help me to listen to music while I'm lying in bed." CORRECT "I don't want to walk today because I have some pain." INCORRECT Question: 40 of 60 CORRECT As a 2 on a scale of 0 to 10, this client's pain is mild. Additional analgesic medication is unnecessary at this time. Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain. Listening to music is an effective nonpharmacological intervention for the management of mild pain. Postoperative clients need to ambulate even if they are having mild pain. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question41loaderationalsprovi de Time Elapsed: 00:42:55 Pause Remaining: 08:20:00 A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? Use a bed exit alarm system. CORRECT Raise four side rails while the client is in bed. INCORRECT Apply one soft wrist restraint. INCORRECT Dim the lights in the client's room. INCORRECT Question: 41 of 60 CORRECT The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain client safety should be attempted for clients who have dementia. Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk for injury. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Q uestion 42l oaded rational s provide Time Elapsed: 00:45:20 Pause Remaining: 08:20:00 A nurse is caring for a client who is postoperative following abdominal surgery. Exhibit 1 Exhibit 2 Exhibit 3 Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the findingagain. Nurses' Notes 1100: Client received from PACU;initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person,place, and time. Client can move Neurological assessment Incisional drainage Urinary output Reported pain level Gastrointestinal assessment Vital signs all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. CORRECT My Answer Neurological assessment is incorrect. The client is oriented to person, place, and time. They are able to move all extremities andhave no obvious indication of neurological compromise. Incisional drainage is incorrect. While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to bereported to the provider unless drainage continues or increases over time. Urinary output is correct. A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should assess the catheter's placement and potential for blockage due to their reduced urine output. This finding should be reported to the provider. Reported pain level is correct. The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increas ing. This findin g should be reported to the provider. Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide. Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider. Question: 42 of 60 CORRECT RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question43loaderationalsprovi de Time Elapsed: 00:46:46 Pause Remaining: 08:20:00 A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? Contact INCORRECT Droplet CORRECT Airborne INCORRECT Protective INCORRECT Question: 43 of 60 CORRECT Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections. Droplet 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. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions. 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. Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question4loaderationalsprovi de Time Elapsed: 00:48:43 Pause Remaining: 08:20:00 A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the n urse plan to take? Insert the catheter at a 45° angle. INCORRECT Place the client's arm in a dependent position. CORRECT Shave excess hair from the insertion site. INCORRECT Initiate IV therapy in the veins of the hand. INCORRECT Question: 44 of 60 CORRECT Generally, the nurse should insert the catheter at a 10° to 30° angle. However, for an older adult client, an angle of 10° to 15° is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue. The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. The nurse should avoid using the fragile veins of an older adult's hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client's hand can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility. RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE RN Fundamental s Online Practice 2019 A with NGN CLOSE Question45loaderationalsprovi de Time Elapsed: 00:49:56 Pause Remaining: 08:20:00 A nurse in a provider's clinic is caring for a client who has heart failure. Exhibit 1 Exhibit 2 Vital Signs First Clinic Visit: Temperature 36.7° C (98° F)Heart rate 106/min Respirations 26/min BP 162/88 mm Hg Oxygen saturation 93% on room air A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? "I have been weighing myself every other morning." "I am trying to decrease my intake of foods with potassium." "I am limiting my sodium intake to 2 grams daily." "I am eating fewer potato chips and more fruit for snacks." "I lie down and rest after meals." "I know to call my doctor if I gain 3 pounds or more in 2 days." Weight 83.9 kg (185 lb) Second Clinic Visit: Temperature 36.7° C (98° F)Heart rate 86/min Respirations 22/min BP 142/78 mm Hg Oxygen saturation 94% on room air Weight 81.6 kg (180 lb) CORRECT "I have been weighing myself every other morning" My An