ATI PN Fundamental proctored Exam with correct answers

ATI PN Fundamental proctored Exam with correct answers A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take? a. Give detailed instructions for the client to follow. b. Complete the bath even if the client is in distress. c. Use distractions when bathing the client. d. Allow the client to select the temperature of the bath water. -ans- c A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take? a. Apply intermittent suction during catheter insertion b. Suction the client's airway for 20 seconds with each pass c. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning d. decrease suction pressure to 150 mm Hg if the O2 sat levels drop during suctioning -ans- a A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity? a. Provide guided imagery exercises to the client. b. Refrain from discussing the client's prognosis c. Suggest that the client keep a journal. d. Encourage the client to share their life story. -ans- b A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take? A. Attach the restraints securely to the side rails of the client's bed. B. Apply the restraints to allow as little movement as possible C.Allow room for two fingers to fit between the clients skin and the restraints d. remove the restraints every 4 hours -ans- c A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? a. Determine areas of resonance across the abdomen using a systematic approach b. Expose the client's abdomen to look for changes in appearance c. Perform abdominal palpation by pressing gently with the finger pads d. Use the diaphragm of the stethoscope to listen for bowel sounds -ans- b A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority? a. Determine the client's reading ability b. Review the use of an artificial larynx c. With the client schedule a support session d. For the client explain the techniques of esophageal speech -ans- d A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply) a. I will use the bars when getting in and out of the bath tub b. I need to check my medications for expiration dates c. I need to have a fire escape plan with my family d. I will apply tape over frayed areas of electrical cords e. I need to set my hot water heater to 140 degrees Fahrenheit -ans- a, b, c A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? a. Changing the dressing for a client who has a stage 3 pressure injury b. Determining a client's response to a diuretic c. Comparing radial pulses for a client who is postoperative d.Providing postmortem care to a client -ans- d A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements? A. I take ginkgo biloba for a headache B. I take echinacea to control my cholesterol C. I use ginger when I get car sick D. I use garlic for my menopausal symptoms -ans- c A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? A. Wear a mask when working within 3 feet of the client B. Administer metronidazole C. Don protective eyewear before entering the room. D. Place the client in a negative airflow room. -ans- a A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? A. Droplet B. Airbornes c. protective environment d. contact -ans- b A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make? A. Have your child drink one large glass of water. B. Hang up and call a poison control center hotline. C. Bring your child into the clinic later today. D. Induce vomiting in your child with syrup of ipecac. -ans- a A nurse is documenting a client's medical record. Which of the following entries should the nurse record. A. Oral temperature slightly elevated at 0800 B. Administered pain medication C. Incision without redness or drainage D. Drank adequate amounts of fluid with meals. -ans- b A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Brush the clients teeth daily C. Apply mineral oil to the client's lips D. Rinse the client's mouth with an alcohol-based mouthwash -ans- a A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify which of the following situations is an example of negligence? A. A nurse administers a medication without first identifying the client. B. An assistive personnel discusses client care in the facility cafeteria with visitors present. C. A nurse begins a blood transfusion without obtaining consent. D. An assistive personnel prevents a client from leaving the facility. -ans- c A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take? A. Wear sterile gloves when collecting the specimen. B. Offer the client oral hygiene after the collection C. Collect the specimen in the evening. D Collect 1 ml of sputum. -ans- b A nurse is assessing an older client. Which of the following findings should the nurse expect? a. Decreased sense of balanced b. Increased nighttime sleeping c. Heightened sense of pain d. Nighttime urinary incontinence -ans- a A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (select all that apply) a. "Cut the opening of the pouch 1⁄8 of an inch larger than the stoma " b. "Place a piece a gauze over the stoma while changing the pouch" c. "Use povidone-iodine to clean around the stoma" d. "Empty the ostomy pouch when it becomes one-third full of contents" e. expect the stoma to turn a purple-blue color as its heals" -ans- a, b, c, d A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? a. "Request that an assistive personnel interpret the information for the client" b. "Use proper medical terms when giving information to the client" c. "Offer written information in the client's language" d. "Avoid using gestures when speaking to the client" -ans- c