ATI RN Fundamentals Proctored Focus
A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake
C. Encourage the client to limit activity & rest
D. Allow the client to shiver to dispel excess heat
E. Assist the client w/oral hygiene frequently
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
A. "Don't measure the client's temp rectally."
B. "Count the client's radial pulse for 30 sec & multiply by 2."
C. "Don't let the client know you are counting her respirations."
D. "Let the client rest for 5 mins before you measure her BP."
The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this
way increases the risk for bleeding.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands. C. The client seemed to welcome having a "day off" from physical therapy D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all. A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it
is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist
C. Physical therapist
D. Social worker
D. social worker
A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker
B. Certified nursing assistant
C. Registered dietitian D. Occupational therapist
An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all. A. Provider
B. CNA
C. Pharmacist
D. RN
E. Respiratory therapist
A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker
B. CNA
C. Occupational therapist
D. Speech-language pathologist
A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties
A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all. A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs
A, B, C, E
Determining pain level requires assessment, which is the job of the licensed personnel.
A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake
C. Encourage the client to limit activity & rest
D. Allow the client to shiver to dispel excess heat
E. Assist the client w/oral hygiene frequently
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
A. "Don't measure the client's temp rectally."
B. "Count the client's radial pulse for 30 sec & multiply by 2."
C. "Don't let the client know you are counting her respirations."
D. "Let the client rest for 5 mins before you measure her BP."
The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this
way increases the risk for bleeding.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands. C. The client seemed to welcome having a "day off" from physical therapy D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all. A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it
is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A. Registered dietitian B. Occupational therapist
C. Physical therapist
D. Social worker
D. social worker
A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker
B. Certified nursing assistant
C. Registered dietitian D. Occupational therapist
An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all. A. Provider
B. CNA
C. Pharmacist
D. RN
E. Respiratory therapist
A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker
B. CNA
C. Occupational therapist
D. Speech-language pathologist
A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties
A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all. A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs
A, B, C, E
Determining pain level requires assessment, which is the job of the licensed personnel.
A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
