ATI PN Fundamentals Online Practice 2020 B with NGN

ATI PN Fundamentals Online Practice 2020 B with NGN A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take? a. offer information about alternative therapies to the procedure b. contact a family member to convince the client to change their mind c. tell the client the benefits of the surgery d. notify the charge nurse of the client's concerns - ANSWER-Notify the charge nurse of the client's concerns. The nurse should notify the charge nurse of the client's concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure. .A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse? a. gathering the client's personal belongings b. removing the client's dentures c. placing absorbent pads under the client's buttocks d. closing the client's eyes - ANSWER-Removing the client's dentures. The client's dentures should remain in place in order to give the face a natural appearance. -The nurse should determine what items need to remain with the client's body. All other belongings should be gathered and given to the client's family. -Absorbent pads are placed under the buttocks to absorb feces and urine released because of relaxation of the sphincter muscles. -The deceased client's eyes should be closed by holding them gently shut for a few seconds. .A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? a. sit beside the client b. speak slowly and loudly to the client c. dim the lights on the client's room d. choose a private room for the interview - ANSWER-Choose a private room for the interview. The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying. .A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? a. reduce intake of calcium-rich foods b. use sunscreen with skin protection factor (SPF) of 8 c. take vitamin D supplements d. use tanning bed 2 hr weekly - ANSWER-Take Vitamin D supplements . The human body requires sunlight exposure to synthesize vitamin D. Therefore, the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D. .A nurse in a providers clinic is caring for a client who has heart failure. The nurse is evaluating the client's understanding of the teaching. Select three client statements that indicate an understanding of the teaching: a. "I know to call my doctor if I gain 3 pounds or more in 2 days" b. "I am eating fewer potato chips and more fruit for snacks" c. "I am limiting my sodium intake to 2 grams daily" d. "I am trying to decrease my intake of foods with potassium" e. "I have been weighing myself twice a week" - ANSWER-"I know to call my doctor if I gain 3 pounds or more in 2 days" is correct. The client should monitor their weight daily and call their provider for a weight gain of 3 lb or greater in 2 days to prevent an exacerbation of their heart failure. "I am eating fewer potato chips and more fruit for snacks" is correct. Chips are a processed snack food that contain increased amounts of sodium. Additionally, fruits contain electrolytes and fiber, both of which are important in controlling blood pressure and lipid levels. "I am limiting my sodium intake to 2 grams daily" is correct. Clients who have heart failure should maintain a sodium intake of between 2 to 3 g daily. .A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation? a. completion of an incident report b. name of the nurse certifying the client's death c. release of personal belonging form d. one client identifier at the client's time of death - ANSWER-Release of personal belongings form. The nurse should document the release of the client's personal belongings form and the articles the nurse gave to the family. -The nurse should not document the completion of an incident report in the client's medical record. -The nurse should document the name of the provider who certified the death of the client. -The nurse should document the identification of the client using two identifiers at the time of death and compare these with the identifiers in the client's medical record. .A nurse is admitting a client. The nurse is reviewing the client's medical record. Nurses Notes: -0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. -1030:Client has swollen cervical lymph nodes on palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and is diaphoretic. Reports poor appetite. Chest x-ray obtained and positive for pneumonia. Blood pressure 110/68 mm Hg Heart rate 110/min Respiratory rate 24/min Temperature 38.6° C (101.5° F)Oxygen saturation 91% on room air -Which of the following actions should the nurse take? select all that apply a. stay at least 0.9 m away from the client when possible b. initiate droplet precautions c. request prescription for an antihypertensive medication d. wear an N95 mask when providing care to the client e. apply oxygen at 2L/min via nasal cannula f. request a prescription for an - ANSWER--Place the client in droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets that are greater than 5 microns in the air. Therefore, the nurse should place the client in droplet isolation. -Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. -Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has temperature that is greater than 38° C (100.4° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. -Stay at least 0.9 m (3 feet) away from the client when possible is correct. The nurse should identify that droplet precautions include wearing a mask and maintaining a distance of at least 0.9 m (3 feet) from the client when possible. .A nurse is assisting in the care of a client who has pancreatitis. Select three tasks the nurse should delegate to the assistive personnel. a. transfer the client from a wheelchair to the bed b. measure the client's intake and output c. collect data about the client's pain level d. insert an NG tube for the client e. document the client's vital signs - ANSWER-a. transfer the client from a wheelchair to the bed b. measure the client's intake and output e. document the client's vital signs .A nurse is assisting with caring for a client who has a newly placed ileostomy. Nurses Notes: 0800 - Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds are present in all quadrants. 1200 - Stoma site appears dark purple with blistering on the skin around the stoma. Slight leakage of the stool noted underneath the wafer. Pouch is three-fourths full of brown, liquid stool. Complete the following sentence by using the following options: -The nurse should first address the __________ a. color of the stoma b. Client's hemoglobin level c. Leakage underneath the wafer -Followed by the ______________ a. ostomy pouch seal b. Skin condition around the stoma c. amount of stool in the pouch - ANSWER-Dropdown 1 Color of the stoma is correct. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel. The nurse should notify the charge nurse immediately. Client's hemoglobin level is incorrect. The nurse should report the client's hemoglobin level because it is greater than the expected reference range. However, there is another finding that the nurse should address first. Leakage underneath the wafer is incorrect. The nurse should address the leakage underneath the wafer because it can cause irritation to the skin surrounding the stoma. However, there is another finding that the nurse should address first. Dropdown 2 Ostomy pouch seal is incorrect. The nurse should address the ostomy pouch seal because it can cause irritation to the skin surrounding the stoma. However, there is another finding that the nurse should address next. Skin condition around the stoma is correct. The nurse should identify that the skin condition around the stoma is the next priority finding to address because this places the client at risk for infection. Amount of stool in the pouch is incorrect. The nurse should address the amount of stool in the pouch to avoid further leakage, which can cause irritation. However, there is another finding that the nurse should address next. .A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?