Science Medicine Nursing
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A charge nurse is discussing the responsibility of nurses d. have family members wear a gown and gloves when visiting
caring for clients who have Clostridium difficile infection.
Which of the following information should the nurse A client who has a Clostridium difficile infection requires a private room, but a
include in the teaching? negative airflow system is not necessary.
a. assign the client to a room with a negative airflow Use alcohol-based hand sanitizer when leaving the client's room. The nurse
system should use soap and water for hand hygiene because alcohol-based hand
b. use alcohol-based hand sanitizer when leaving the sanitizer does not kill Clostridium difficile spores.
client's room Clean contaminated surfaces in the client's room with a phenol solution.The nurse
c. clean contaminated surfaces in the client's room with a should use a phenol solution to clean surfaces contaminated with bacteria and
phenol solution fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach
d. have family members wear a gown and gloves when is an example of a disinfectant that kills spores.
visiting Have family members wear a gown and gloves when visiting.Nurses are
responsible for ensuring that family members wear a gown and gloves to prevent
the transmission of Clostridium difficile spores. Staff must also wear gowns and
gloves.
,A nurse is giving change of shift report about a client b. breath sounds
they admitted earlier that day who has pneumonia. Which
of the following pieces of info is the priority for the nurse When using the airway, breathing, circulation approach to client care, the nurse
to provide? should determine that the priority information to provide is the current status of
a. admitting diagnosis the client's breath sounds. Knowing the client's admitting diagnosis is essential for
b. breath sounds planning care and following critical pathways; however, other information is the
c. body temperature nurse's priority to provide. Body temperature
d. diagnostic test results Knowing the client's current body temperature is essential for planning care and
following critical pathways; however, other information is the nurse's priority to
provide. Knowing diagnostic test results is essential for planning care and
following critical pathways; however, other information is the nurse's priority to
provide.
A nurse is preparing to delegate client care tasks to an a. ambulating a client who is postop
assistive personnel(AP). Which of the following tasks
should the nurse delegate? Ambulating a client is within the range of function of an AP. The nurse can
a. ambulating a client who is postop delegate tasks to the AP that do not require special skills, assessment, or teaching.
b. inserting an indwelling urinary catheter for a client Inserting an indwelling urinary catheter for a clientIndwelling urinary catheter
c. demonstrating the use of an incentive spirometer to a insertion requires advanced nursing judgment and sterile technique. This task is
client outside the range of function of an AP.
d. confirming that a client's pain has decreased after Demonstrating the use of an incentive spirometer to a clientClient education
receiving an analgesic requires advanced nursing knowledge and is outside the range of function of an
AP.
Confirming that a client's pain has decreased after receiving an
analgesicEvaluating a client's pain level requires advanced nursing judgment and
is outside the range of function of an AP.
A nurse enters a client's room and finds her on the floor. c. "client found lying on the floor"
The client's roommate reports that the client was trying to
get out of bed and fell over the side rail onto the floor. An incident report is an internal document that is part of a facility's risk
Which of the following statements should the nurse management system. The nurse should not document completion of an incident
document about this incident? report in the client's medical record for the facility's protection in the event of
a. "incident report completed" litigation.
b. "client climbed over the side rails" "Client climbed over the side rails."Unless the nurse witnessed the client climbing
c. "client found lying on the floor" over the bed's side rails, this statement is not an objective account of the nurse's
d. "client was trying to get out of bed" findings.
"Client found lying on floor." The nurse should include documentation of
information that is descriptive and objective concerning what the nurse actually
observed, without including any opinions or judgments about motives or cause.
"Client was trying to get out of bed."Unless the nurse witnessed the client trying
to get out of bed, this statement is not an objective account of the nurse's
findings.
, A nurse is caring for a client who has a prescription for c. cleanse the wound from the center outward
wound irrigation. Which of the following actions should
the nurse take? The nurse should wear clean gloves to remove the old dressing.
a. wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the
b. warm the irrigation solution to 40.5(105 degrees irrigation solution to body temperature.
farenheit) Cleanse the wound from the center outward. The nurse should clean the wound
c. cleanse the wound from the center outward from the center outward to prevent introduction of micro-organisms from the
d. use a 20 mL syringe to irrigate the wound. outer skin surface.
Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe
to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but
effective amount of pressure for wound irrigation.
A nurse is admitting a client who has rubella. Which of the a. droplet
following types of transmission based precautions should
the nurse initiate? Droplet precautions are a requirement for clients who have infections that spread
a. droplet via droplet nuclei that are larger than 5 microns in diameter, including influenza,
b. airborne rubella, meningococcal pneumonia, and streptococcal pharyngitis.
c. contact Airborne precautions are a requirement for clients who have infections that
d. protective environment spread via droplet nuclei that are smaller than 5 microns in diameter, including
varicella, tuberculosis, and measles.
Contact precautions are a requirement for clients who have infections that spread
via direct contact with another person or contact with the environment, including
vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus,
and scabies.
Protective environment Clients who have a compromised immune system, such as
those who have had an allogeneic hematopoietic stem cell transplant, require a
protective environment.
The nurse is providing discharge teaching for a client who a,c,d
has a new prescription for a home oxygen concentrator.
Which of the following instructions should the nurse Check the cord routinely for frays or tearing is correct. Oxygen concentrators
provide to the client and his family? select all that apply. require electrical power. Safe use of this delivery system includes assessing the
a. check the cord routinely for frays and tearing electrical function of the device; therefore, the nurse should instruct the client to
b. keep the unit at least 1.2 m (4 feet) away from a gas routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away
stove from a gas stove is incorrect. Safe use of home oxygen equipment includes
c. consider purchasing a generator for power backup keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a
d. observe for signs of hypoxia fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat
d. select synthetic clothing and bedding sources.Consider purchasing a generator for power backup is correct. Loss of
electricity prevents the oxygen concentrator from functioning and could deprive
the client of necessary oxygen. The nurse should also instruct the family to have
the client placed on their municipality's priority list for restoring power after an
outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct
the family to observe for
ATI Fundamentals Retake
11 studiers recently Leave the first rating
Students also studied
Flashcard sets Study guides
ATI RN Maternal Newborn 2023 Fundamentals 2026 Proctor with act... Fundamentals ATI Proctored Exam S... ATI fun
Teacher 59 terms Teacher 73 terms 202 terms 120 term
lucianawinnie823 Preview TutorDk Preview jackline_ndambiri Preview aev
Terms in this set (172) Hide definitions
A charge nurse is discussing the responsibility of nurses d. have family members wear a gown and gloves when visiting
caring for clients who have Clostridium difficile infection.
Which of the following information should the nurse A client who has a Clostridium difficile infection requires a private room, but a
include in the teaching? negative airflow system is not necessary.
a. assign the client to a room with a negative airflow Use alcohol-based hand sanitizer when leaving the client's room. The nurse
system should use soap and water for hand hygiene because alcohol-based hand
b. use alcohol-based hand sanitizer when leaving the sanitizer does not kill Clostridium difficile spores.
client's room Clean contaminated surfaces in the client's room with a phenol solution.The nurse
c. clean contaminated surfaces in the client's room with a should use a phenol solution to clean surfaces contaminated with bacteria and
phenol solution fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach
d. have family members wear a gown and gloves when is an example of a disinfectant that kills spores.
visiting Have family members wear a gown and gloves when visiting.Nurses are
responsible for ensuring that family members wear a gown and gloves to prevent
the transmission of Clostridium difficile spores. Staff must also wear gowns and
gloves.
,A nurse is giving change of shift report about a client b. breath sounds
they admitted earlier that day who has pneumonia. Which
of the following pieces of info is the priority for the nurse When using the airway, breathing, circulation approach to client care, the nurse
to provide? should determine that the priority information to provide is the current status of
a. admitting diagnosis the client's breath sounds. Knowing the client's admitting diagnosis is essential for
b. breath sounds planning care and following critical pathways; however, other information is the
c. body temperature nurse's priority to provide. Body temperature
d. diagnostic test results Knowing the client's current body temperature is essential for planning care and
following critical pathways; however, other information is the nurse's priority to
provide. Knowing diagnostic test results is essential for planning care and
following critical pathways; however, other information is the nurse's priority to
provide.
A nurse is preparing to delegate client care tasks to an a. ambulating a client who is postop
assistive personnel(AP). Which of the following tasks
should the nurse delegate? Ambulating a client is within the range of function of an AP. The nurse can
a. ambulating a client who is postop delegate tasks to the AP that do not require special skills, assessment, or teaching.
b. inserting an indwelling urinary catheter for a client Inserting an indwelling urinary catheter for a clientIndwelling urinary catheter
c. demonstrating the use of an incentive spirometer to a insertion requires advanced nursing judgment and sterile technique. This task is
client outside the range of function of an AP.
d. confirming that a client's pain has decreased after Demonstrating the use of an incentive spirometer to a clientClient education
receiving an analgesic requires advanced nursing knowledge and is outside the range of function of an
AP.
Confirming that a client's pain has decreased after receiving an
analgesicEvaluating a client's pain level requires advanced nursing judgment and
is outside the range of function of an AP.
A nurse enters a client's room and finds her on the floor. c. "client found lying on the floor"
The client's roommate reports that the client was trying to
get out of bed and fell over the side rail onto the floor. An incident report is an internal document that is part of a facility's risk
Which of the following statements should the nurse management system. The nurse should not document completion of an incident
document about this incident? report in the client's medical record for the facility's protection in the event of
a. "incident report completed" litigation.
b. "client climbed over the side rails" "Client climbed over the side rails."Unless the nurse witnessed the client climbing
c. "client found lying on the floor" over the bed's side rails, this statement is not an objective account of the nurse's
d. "client was trying to get out of bed" findings.
"Client found lying on floor." The nurse should include documentation of
information that is descriptive and objective concerning what the nurse actually
observed, without including any opinions or judgments about motives or cause.
"Client was trying to get out of bed."Unless the nurse witnessed the client trying
to get out of bed, this statement is not an objective account of the nurse's
findings.
, A nurse is caring for a client who has a prescription for c. cleanse the wound from the center outward
wound irrigation. Which of the following actions should
the nurse take? The nurse should wear clean gloves to remove the old dressing.
a. wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the
b. warm the irrigation solution to 40.5(105 degrees irrigation solution to body temperature.
farenheit) Cleanse the wound from the center outward. The nurse should clean the wound
c. cleanse the wound from the center outward from the center outward to prevent introduction of micro-organisms from the
d. use a 20 mL syringe to irrigate the wound. outer skin surface.
Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe
to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but
effective amount of pressure for wound irrigation.
A nurse is admitting a client who has rubella. Which of the a. droplet
following types of transmission based precautions should
the nurse initiate? Droplet precautions are a requirement for clients who have infections that spread
a. droplet via droplet nuclei that are larger than 5 microns in diameter, including influenza,
b. airborne rubella, meningococcal pneumonia, and streptococcal pharyngitis.
c. contact Airborne precautions are a requirement for clients who have infections that
d. protective environment spread via droplet nuclei that are smaller than 5 microns in diameter, including
varicella, tuberculosis, and measles.
Contact precautions are a requirement for clients who have infections that spread
via direct contact with another person or contact with the environment, including
vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus,
and scabies.
Protective environment Clients who have a compromised immune system, such as
those who have had an allogeneic hematopoietic stem cell transplant, require a
protective environment.
The nurse is providing discharge teaching for a client who a,c,d
has a new prescription for a home oxygen concentrator.
Which of the following instructions should the nurse Check the cord routinely for frays or tearing is correct. Oxygen concentrators
provide to the client and his family? select all that apply. require electrical power. Safe use of this delivery system includes assessing the
a. check the cord routinely for frays and tearing electrical function of the device; therefore, the nurse should instruct the client to
b. keep the unit at least 1.2 m (4 feet) away from a gas routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away
stove from a gas stove is incorrect. Safe use of home oxygen equipment includes
c. consider purchasing a generator for power backup keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a
d. observe for signs of hypoxia fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat
d. select synthetic clothing and bedding sources.Consider purchasing a generator for power backup is correct. Loss of
electricity prevents the oxygen concentrator from functioning and could deprive
the client of necessary oxygen. The nurse should also instruct the family to have
the client placed on their municipality's priority list for restoring power after an
outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct
the family to observe for
