ATI Practice B | VERIFIED SOLUTION

ATI Practice B A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following information should the nurse include in the teaching? • Assign the client to a room with a negative airflow system. o A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary. • Use alcohol-based hand sanitizer when leaving the client's room. o The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. • Clean contaminated surfaces in the client's room with a phenol solution. o The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. • Have family members wear a gown and gloves when visiting. o Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves. A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? • Admitting diagnosis o Knowing the client's admitting diagnosis is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. • Breath sounds o When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. • Body temperature o Knowing the client's current body temperature is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. • Diagnostic test results o Knowing diagnostic test results is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? • Ambulating a client who is postoperative o Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching. • Inserting an indwelling urinary catheter for a client o Indwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This task is outside the range of function of an AP. • Demonstrating the use of an incentive spirometer to a client o Client education requires advanced nursing knowledge and is outside the range of function of an AP. • Confirming that a client's pain has decreased after receiving an analgesic o Evaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? • "Incident report completed." o An incident report is an internal document that is part of a facility's risk management system. The nurse should not document completion of an incident report in the client's medical record for the facility's protection in the event of litigation. • "Client climbed over the side rails." o Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an objective account of the nurse's findings. • "Client found lying on floor." o The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause. “client found lying on floor” is correct • "Client was trying to get out of bed." o Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective account of the nurse’s findings.