ATI PN FUNDAMENTALS 2020 B

ATI PN FUNDAMENTALS 2020 B ATI PN FUNDAMENTALS 2020 B ATI PN Fundamentals 2020 B A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? Remove the cover gown in the client's room after providing care. A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following Actual loss A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) Keep the family updated about the client's status is correct. Encourage the family to comb the client's hair is correct. Tell the client'sfamily what to expect as the client's death nears is correct. A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A piston syringe A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? Performance of a paracentesis A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider? A purple-colored stoma A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching "You should cover your mouth with a tissue when you cough." • A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? "It must be difficult facing this type ofsurgery." A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? "Please don't tell my doctor, but I am taking my partner's oxycodone." A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 13.6 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 Choose a private room for the interview A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? 3+ pitting edema A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? A thready pulse A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? Guided imagery • A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities? A physical therapist who is involved in the client's care • A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions? Orthopneic A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? ego integrity vs despair A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.) Tell the nurses to change the topic of conversation. • 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? • Release of personal belongings form A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make? "Describe your concerns about sleeping to me A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation? "Became short of breath when ambulating." • A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Assess the client's gag reflex Position the client on theirside with their head turned to the side Place a towel under the client's head with an emesis basin under their chin Separate the client's upper and lower teeth with an oral airway device Cleanse the client's mouth using a toothbrush A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? "I know that I can change my advance directives if I need to in the future." A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care associated infections for these clients? (Select all that apply.) Wash hands after removing gloves. Use antimicrobial hand gel after relling a client's water pitcher. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. 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? Take vitamin D supplements. A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? The client's output was 60 mL for the past 3 hr. A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching "I will place a gel pad directly above your pubic area before I place the probe." A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask? Have you had small liquid stools? A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? the client has tenderness and warmth in their calf. A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? Remove the staple from the skin after both sides are visible A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? "Do you consume pork products? A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take? Measure the client's gastric residual before each feeding 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? • Pallor with scaly skin A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? Ask the client what they already know about meal planning. • A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? Clean the perineal area at least once a day. A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? "Stand with your feet together and your arms at your sides." • 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? Notify the charge nurse of the client's concerns A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? Client states, "I started to itch after taking that medication." A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A client who hasjust experienced the death of their child A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure? Headache A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands? Turn o the faucet with a clean paper towel after drying hands. A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? "I will remove allstuffed animals from my baby's crib." • A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? Providing client information to another nurse at change of shift • A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide? "Provide mouth care to them at least every 2 hours." A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Use printed materials written in the client's language. • A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? latex A nurse is evaluating the crutch-walking technique of a client who is required to keep weight o their right leg. Which of the following is the proper crutch gait for this client? three-point A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first? Perform a bladder scan. A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include? "This dressing allows the wound bed to breathe." A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? Instruct the client to tilt their head forward while eating. A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? "Perform muscle relaxation before bedtime." • A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching? "I should remove constrictive clothing prior to measuring my blood pressure." A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? Use warm water when bathing the client. A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? Attach a humidifier to the base of the ow meter. • 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? Removing the client's dentures • A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? A client who has measles A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan? Support the client's feet with foot boots. A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? Count the client'sradial and apical pulses simultaneously with another nurse. A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? "Tighten your stomach muscles." •