ATI Learning System RN: Fundamentals Final Questions with correct answers after helping to reposition a patient who reports SOB what actions should the nurse
take next? Correct Answer - observe rate, depth, character of pts respirations
-priority: nurse must first assess and collect further data before notifying the provider or applying another nursing intervention
-nurse can also encourage deep breathing
-nurse can administer O2 if pt is experiencing dyspnea
-nurse can give pt a back rub to promote relaxation to reduce dyspnea
a patient starts to experience a seizure while sitting in a chair. what actions should the nurse take? Correct Answer - lower the pt to the flood and place a pad under pts head
-reduce risk of injury
-avoid inserting anything into the mouth d/t injury such as broken teeth
-do not attepmy to lift during active seizure
a home health nurse is planning to provide health promotion activities to a community. what activities is an example of primary prevention? Correct Answer -
educating pts about recommended immunization schedule for adults
-primary prevention = education on disease prevention
-secondary prevention focuses on measures to ID early stages of a condition; screening -tertiary prevention occurs after diagnosis of condition and focuses to limit complications the nurse should convey the patient's pain status in which portion of the I-SBAR report? Correct Answer - assessment
-Situation= problems pt experiencing
-Background= medical history, lab findings, allergies, code status
-Assessment= assessment data and findings collected by nurse for pt
-Recommendation= recommendations about Tx and asks provider about additional Tx
nurse should identify which findings indicate infiltration of a peripheral IV site? Correct Answer - edema at infusion site
-d/t fluid entering subcutaneous tissue
-redness, warmth at site indicates phlebitis/ infection
-oozing blood at site indicates that IV system isn't intact
the provider instructed a patient recovering from lung cancer he could resume lower-intensity activities of daily living. what activities should the nurse recommend to the patient? Correct Answer - washing dishes
-cleaning windows and -sweeping is moderate-intensity
-shoveling snow is high-intensity
what assessment provides the most accurate measure of a patients fluid status for a patient who has acute renal failure? Correct Answer - daily weight -gain/loss of 1 kg (2.2 lbs) indicates gain/loss of 1 L of fluid
-B/P and USP can indicate gain/loss of fluid but not most accurate
-I&O's reflect pts fluid status but not most accurate
what method of assessment should a nurse use first when assessing a patient who reports feeling bloated for several weeks? Correct Answer - 1. inspection
2. auscultation
3. percussion
4. palpation
a nurse should ensure that a written consent form has been signed by which of the following patients? Correct Answer - a pt who has a Px for a transfusion of RBC's
-procedure which carries risk
-pts admitted to hospital sign general consent form when admitted which allows consent for diagnostic exams
-implied consent is given through acts such as holding out an arm or cooperation during painful, uncomfortable procedures
a nurse in a long-term care facility is admitting a patient who is incontinent and smells strongly of urine. his partner, who has been taking care of him at home, is embarrassed and apologizes for the smell. what responses should the nurse make? Correct Answer - "it must be difficult to care for someone who is confined to bed"
-therapeutic and addresses partner's feelings
take next? Correct Answer - observe rate, depth, character of pts respirations
-priority: nurse must first assess and collect further data before notifying the provider or applying another nursing intervention
-nurse can also encourage deep breathing
-nurse can administer O2 if pt is experiencing dyspnea
-nurse can give pt a back rub to promote relaxation to reduce dyspnea
a patient starts to experience a seizure while sitting in a chair. what actions should the nurse take? Correct Answer - lower the pt to the flood and place a pad under pts head
-reduce risk of injury
-avoid inserting anything into the mouth d/t injury such as broken teeth
-do not attepmy to lift during active seizure
a home health nurse is planning to provide health promotion activities to a community. what activities is an example of primary prevention? Correct Answer -
educating pts about recommended immunization schedule for adults
-primary prevention = education on disease prevention
-secondary prevention focuses on measures to ID early stages of a condition; screening -tertiary prevention occurs after diagnosis of condition and focuses to limit complications the nurse should convey the patient's pain status in which portion of the I-SBAR report? Correct Answer - assessment
-Situation= problems pt experiencing
-Background= medical history, lab findings, allergies, code status
-Assessment= assessment data and findings collected by nurse for pt
-Recommendation= recommendations about Tx and asks provider about additional Tx
nurse should identify which findings indicate infiltration of a peripheral IV site? Correct Answer - edema at infusion site
-d/t fluid entering subcutaneous tissue
-redness, warmth at site indicates phlebitis/ infection
-oozing blood at site indicates that IV system isn't intact
the provider instructed a patient recovering from lung cancer he could resume lower-intensity activities of daily living. what activities should the nurse recommend to the patient? Correct Answer - washing dishes
-cleaning windows and -sweeping is moderate-intensity
-shoveling snow is high-intensity
what assessment provides the most accurate measure of a patients fluid status for a patient who has acute renal failure? Correct Answer - daily weight -gain/loss of 1 kg (2.2 lbs) indicates gain/loss of 1 L of fluid
-B/P and USP can indicate gain/loss of fluid but not most accurate
-I&O's reflect pts fluid status but not most accurate
what method of assessment should a nurse use first when assessing a patient who reports feeling bloated for several weeks? Correct Answer - 1. inspection
2. auscultation
3. percussion
4. palpation
a nurse should ensure that a written consent form has been signed by which of the following patients? Correct Answer - a pt who has a Px for a transfusion of RBC's
-procedure which carries risk
-pts admitted to hospital sign general consent form when admitted which allows consent for diagnostic exams
-implied consent is given through acts such as holding out an arm or cooperation during painful, uncomfortable procedures
a nurse in a long-term care facility is admitting a patient who is incontinent and smells strongly of urine. his partner, who has been taking care of him at home, is embarrassed and apologizes for the smell. what responses should the nurse make? Correct Answer - "it must be difficult to care for someone who is confined to bed"
-therapeutic and addresses partner's feelings
