ATI Fundamentals Retake
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1. A charge nurse is dis- d. have family members wear a gown and gloves when visiting
cussing the responsi-
bility of nurses caring A client who has a Clostridium difficile infection requires a private room,
for clients who have but a negative airflow system is not necessary.
Clostridium difficile in- Use alcohol-based hand sanitizer when leaving the client's room. The
fection. Which of the nurse should use soap and water for hand hygiene because alco-
following information hol-based hand sanitizer does not kill Clostridium difficile spores.
should the nurse in- Clean contaminated surfaces in the client's room with a phenol solu-
clude in the teaching? tion.The nurse should use a phenol solution to clean surfaces contami-
a. assign the client to nated with bacteria and fungi. However, phenol does not kill Clostridium
a room with a negative difficile spores. Chlorine bleach is an example of a disinfectant that kills
airflow system spores.
b. use alcohol-based Have family members wear a gown and gloves when visiting.Nurses are
hand sanitizer when responsible for ensuring that family members wear a gown and gloves
leaving the client's to prevent the transmission of Clostridium difficile spores. Staff must also
room wear gowns and gloves.
c. clean contaminated
surfaces in the client's
room with a phenol so-
lution
d. have family mem-
bers wear a gown and
gloves when visiting
2. A nurse is giving b. breath sounds
change of shift report
about a client they ad- When using the airway, breathing, circulation approach to client care,
mitted earlier that day the nurse should determine that the priority information to provide is
who has pneumonia. the current status of the client's breath sounds. Knowing the client's
Which of the following admitting diagnosis is essential for planning care and following critical
pieces of info is the pri- pathways; however, other information is the nurse's priority to provide.
ority for the nurse to Body temperature
, ATI Fundamentals Retake
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provide? Knowing the client's current body temperature is essential for planning
a. admitting diagnosis care and following critical pathways; however, other information is the
b. breath sounds nurse's priority to provide. Knowing diagnostic test results is essential for
c. body temperature planning care and following critical pathways; however, other information
d. diagnostic test re- is the nurse's priority to provide.
sults
3. A nurse is preparing a. ambulating a client who is postop
to delegate client care
tasks to an assistive Ambulating a client is within the range of function of an AP. The nurse can
personnel(AP). Which delegate tasks to the AP that do not require special skills, assessment, or
of the following tasks teaching.
should the nurse dele- Inserting an indwelling urinary catheter for a clientIndwelling urinary
gate? catheter insertion requires advanced nursing judgment and sterile tech-
a. ambulating a client nique. This task is outside the range of function of an AP.
who is postop Demonstrating the use of an incentive spirometer to a clientClient edu-
b. inserting an cation requires advanced nursing knowledge and is outside the range of
indwelling urinary function of an AP.
catheter for a client Confirming that a client's pain has decreased after receiving an anal-
c. demonstrating the gesicEvaluating a client's pain level requires advanced nursing judgment
use of an incentive and is outside the range of function of an AP.
spirometer to a client
d. confirming that a
client's pain has de-
creased after receiving
an analgesic
4. A nurse enters a c. "client found lying on the floor"
client's room and finds
her on the floor. The An incident report is an internal document that is part of a facility's risk
client's roommate re- management system. The nurse should not document completion of an
ports that the client incident report in the client's medical record for the facility's protection
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
was trying to get out in the event of litigation.
of bed and fell over the "Client climbed over the side rails."Unless the nurse witnessed the client
side rail onto the floor. climbing over the bed's side rails, this statement is not an objective
Which of the following account of the nurse's findings.
statements should the "Client found lying on floor." The nurse should include documentation of
nurse document about information that is descriptive and objective concerning what the nurse
this incident? actually observed, without including any opinions or judgments about
a. "incident report motives or cause.
completed" "Client was trying to get out of bed."Unless the nurse witnessed the client
b. "client climbed over trying to get out of bed, this statement is not an objective account of the
the side rails" nurse's findings.
c. "client found lying on
the floor"
d. "client was trying to
get out of bed"
5. A nurse is caring for c. cleanse the wound from the center outward
a client who has a
prescription for wound The nurse should wear clean gloves to remove the old dressing.
irrigation. Which of Warm the irrigation solution to 40.5° C (105° F).The nurse should warm
the following actions the irrigation solution to body temperature.
should the nurse take? Cleanse the wound from the center outward. The nurse should clean the
a. wear sterile gloves wound from the center outward to prevent introduction of micro-organ-
when removing the old isms from the outer skin surface.
dressing Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL
b. warm the irrigation syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid
solution to 40.5(105 de- create a safe but effective amount of pressure for wound irrigation.
grees farenheit)
c. cleanse the wound
from the center out-
ward
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Study online at https://quizlet.com/_e1zdhu
d. use a 20 mL syringe
to irrigate the wound.
6. A nurse is admitting a a. droplet
client who has rubel-
la. Which of the follow- Droplet precautions are a requirement for clients who have infections
ing types of transmis- that spread via droplet nuclei that are larger than 5 microns in diameter,
sion based precautions including influenza, rubella, meningococcal pneumonia, and streptococ-
should the nurse initi- cal pharyngitis.
ate? Airborne precautions are a requirement for clients who have infections
a. droplet that spread via droplet nuclei that are smaller than 5 microns in diameter,
b. airborne including varicella, tuberculosis, and measles.
c. contact Contact precautions are a requirement for clients who have infections
d. protective environ- that spread via direct contact with another person or contact with the
ment environment, including vancomycin-resistant enterococci, methicillin-re-
sistant Staphylococcus aureus, and scabies.
Protective environment Clients who have a compromised immune sys-
tem, such as those who have had an allogeneic hematopoietic stem cell
transplant, require a protective environment.
7. The nurse is provid- a,c,d
ing discharge teaching
for a client who has Check the cord routinely for frays or tearing is correct. Oxygen concen-
a new prescription for trators require electrical power. Safe use of this delivery system includes
a home oxygen con- assessing the electrical function of the device; therefore, the nurse should
centrator. Which of the instruct the client to routinely check the condition of the cord.Keep the
following instructions unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use
should the nurse pro- of home oxygen equipment includes keeping the unit at least 3.05 m
vide to the client and (10 feet) away from open flames, such as from a fireplace or a gas
his family? select all stove, and at least 2.4 m (8 feet) away from other heat sources.Consider
that apply. purchasing a generator for power backup is correct. Loss of electricity
a. check the cord rou- prevents the oxygen concentrator from functioning and could deprive
Study online at https://quizlet.com/_e1zdhu
1. A charge nurse is dis- d. have family members wear a gown and gloves when visiting
cussing the responsi-
bility of nurses caring A client who has a Clostridium difficile infection requires a private room,
for clients who have but a negative airflow system is not necessary.
Clostridium difficile in- Use alcohol-based hand sanitizer when leaving the client's room. The
fection. Which of the nurse should use soap and water for hand hygiene because alco-
following information hol-based hand sanitizer does not kill Clostridium difficile spores.
should the nurse in- Clean contaminated surfaces in the client's room with a phenol solu-
clude in the teaching? tion.The nurse should use a phenol solution to clean surfaces contami-
a. assign the client to nated with bacteria and fungi. However, phenol does not kill Clostridium
a room with a negative difficile spores. Chlorine bleach is an example of a disinfectant that kills
airflow system spores.
b. use alcohol-based Have family members wear a gown and gloves when visiting.Nurses are
hand sanitizer when responsible for ensuring that family members wear a gown and gloves
leaving the client's to prevent the transmission of Clostridium difficile spores. Staff must also
room wear gowns and gloves.
c. clean contaminated
surfaces in the client's
room with a phenol so-
lution
d. have family mem-
bers wear a gown and
gloves when visiting
2. A nurse is giving b. breath sounds
change of shift report
about a client they ad- When using the airway, breathing, circulation approach to client care,
mitted earlier that day the nurse should determine that the priority information to provide is
who has pneumonia. the current status of the client's breath sounds. Knowing the client's
Which of the following admitting diagnosis is essential for planning care and following critical
pieces of info is the pri- pathways; however, other information is the nurse's priority to provide.
ority for the nurse to Body temperature
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
provide? Knowing the client's current body temperature is essential for planning
a. admitting diagnosis care and following critical pathways; however, other information is the
b. breath sounds nurse's priority to provide. Knowing diagnostic test results is essential for
c. body temperature planning care and following critical pathways; however, other information
d. diagnostic test re- is the nurse's priority to provide.
sults
3. A nurse is preparing a. ambulating a client who is postop
to delegate client care
tasks to an assistive Ambulating a client is within the range of function of an AP. The nurse can
personnel(AP). Which delegate tasks to the AP that do not require special skills, assessment, or
of the following tasks teaching.
should the nurse dele- Inserting an indwelling urinary catheter for a clientIndwelling urinary
gate? catheter insertion requires advanced nursing judgment and sterile tech-
a. ambulating a client nique. This task is outside the range of function of an AP.
who is postop Demonstrating the use of an incentive spirometer to a clientClient edu-
b. inserting an cation requires advanced nursing knowledge and is outside the range of
indwelling urinary function of an AP.
catheter for a client Confirming that a client's pain has decreased after receiving an anal-
c. demonstrating the gesicEvaluating a client's pain level requires advanced nursing judgment
use of an incentive and is outside the range of function of an AP.
spirometer to a client
d. confirming that a
client's pain has de-
creased after receiving
an analgesic
4. A nurse enters a c. "client found lying on the floor"
client's room and finds
her on the floor. The An incident report is an internal document that is part of a facility's risk
client's roommate re- management system. The nurse should not document completion of an
ports that the client incident report in the client's medical record for the facility's protection
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
was trying to get out in the event of litigation.
of bed and fell over the "Client climbed over the side rails."Unless the nurse witnessed the client
side rail onto the floor. climbing over the bed's side rails, this statement is not an objective
Which of the following account of the nurse's findings.
statements should the "Client found lying on floor." The nurse should include documentation of
nurse document about information that is descriptive and objective concerning what the nurse
this incident? actually observed, without including any opinions or judgments about
a. "incident report motives or cause.
completed" "Client was trying to get out of bed."Unless the nurse witnessed the client
b. "client climbed over trying to get out of bed, this statement is not an objective account of the
the side rails" nurse's findings.
c. "client found lying on
the floor"
d. "client was trying to
get out of bed"
5. A nurse is caring for c. cleanse the wound from the center outward
a client who has a
prescription for wound The nurse should wear clean gloves to remove the old dressing.
irrigation. Which of Warm the irrigation solution to 40.5° C (105° F).The nurse should warm
the following actions the irrigation solution to body temperature.
should the nurse take? Cleanse the wound from the center outward. The nurse should clean the
a. wear sterile gloves wound from the center outward to prevent introduction of micro-organ-
when removing the old isms from the outer skin surface.
dressing Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL
b. warm the irrigation syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid
solution to 40.5(105 de- create a safe but effective amount of pressure for wound irrigation.
grees farenheit)
c. cleanse the wound
from the center out-
ward
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
d. use a 20 mL syringe
to irrigate the wound.
6. A nurse is admitting a a. droplet
client who has rubel-
la. Which of the follow- Droplet precautions are a requirement for clients who have infections
ing types of transmis- that spread via droplet nuclei that are larger than 5 microns in diameter,
sion based precautions including influenza, rubella, meningococcal pneumonia, and streptococ-
should the nurse initi- cal pharyngitis.
ate? Airborne precautions are a requirement for clients who have infections
a. droplet that spread via droplet nuclei that are smaller than 5 microns in diameter,
b. airborne including varicella, tuberculosis, and measles.
c. contact Contact precautions are a requirement for clients who have infections
d. protective environ- that spread via direct contact with another person or contact with the
ment environment, including vancomycin-resistant enterococci, methicillin-re-
sistant Staphylococcus aureus, and scabies.
Protective environment Clients who have a compromised immune sys-
tem, such as those who have had an allogeneic hematopoietic stem cell
transplant, require a protective environment.
7. The nurse is provid- a,c,d
ing discharge teaching
for a client who has Check the cord routinely for frays or tearing is correct. Oxygen concen-
a new prescription for trators require electrical power. Safe use of this delivery system includes
a home oxygen con- assessing the electrical function of the device; therefore, the nurse should
centrator. Which of the instruct the client to routinely check the condition of the cord.Keep the
following instructions unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use
should the nurse pro- of home oxygen equipment includes keeping the unit at least 3.05 m
vide to the client and (10 feet) away from open flames, such as from a fireplace or a gas
his family? select all stove, and at least 2.4 m (8 feet) away from other heat sources.Consider
that apply. purchasing a generator for power backup is correct. Loss of electricity
a. check the cord rou- prevents the oxygen concentrator from functioning and could deprive
