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Exam (elaborations)

ATI RN FUNDAMENTALS EXAM PACK 2019 – 2021 Verified Q&A

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A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue the teaching, but check afterward with the surgeon about informed consent -incorrect: The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching. B. Stop the teaching and check with the surgeon about informed consent -The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon. C. Stop the teaching and ask the client to sign an informed consent form -It is not within the nurse’s scope of practice to obtain informed consent from the client. D. Continue the teaching and check the client’s medical record afterward for a signed consent form -The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching. A home health nurse is visiting an older adult client with severe dementia. The client’s son, who serves as her primary caregiver, reports being “exhausted” from working parttime and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation -incorrect: Rehabilitation programs help clients return to optimal functioning after an illness or injury. However, severe dementia will not improve with rehabilitative services. B. Assisted living facility -incorrect: An assisted living facility provides independence for clients who need only limited personal care. A client who has severe dementia needs total care. C. Respite care -Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance. D. Adult day care facility -incorrect: Although adult day care facilities do help family caregivers maintain some aspects of their lifestyle and independence, these facilitates provide care and supervision for clients who need minimal assistance (ex: taking medication, receiving physical therapy, or receiving counseling). They do not provide care for clients who have severe dementia. A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Face away from the client to avoid distraction -incorrect: The nurse should face the client while speaking to offer the client the opportunity to observe facial expressions and gestures. B. Pace speech to allow time for the interpreter to convey the words -The nurse should speak clearly and allow time for the interpreter to convey the message and for the client to receive it. C. Make eye contact with the interpreter when explaining the procedure -incorrect: To enhance the nurse-client relationship, the nurse should direct questions, instructions, and information to the client, not to the interpreter. The client’s focus will be on the interpreter, but it is respectful to continue to address the client and not the interpreter. D. Stand in the background while the interpreter translates the message -incorrect: The nurse should sit at the same level as the client to give the client the opportunity to observe facial expressions and gestures. A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper -incorrect: The nurse should not shake soiled linen because this action can transfer microorganisms. B. Removing a face mask when standing 0.5 m (1.6 ft) from the client -incorrect: The nurse should wear a mask when working within 1m (3.3 ft) of a client who is on droplet precautions to reduce the risk of transferring the particle droplets. C. Assigning another client with the same infection to share the room with the client -The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available. D. Allowing the client to visit a family member in the lobby of the facility -incorrect: The nurse should strictly limit the client’s activity outside the room to reduce the risk of transferring microorganisms. Whenever the client has to leave the room, the nurse should place a mask on the client. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher

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