ATI PN Fundamentals 2020 A

ATI PN Fundamentals 2020 A A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.) Decrease the rate of the feeding A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? Nonrebreather mask A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that 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.) Evacuate clients from the area is the first step. Pull the lever on the fire alarm box is the second step. Close the fire doors on the unit is the third step. Use a fire extinguisher to put out the fire is the fourth step. A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? "Tell me what the afterlife means to you." A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? "When lifting a heavy object, keep it close to your body." A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching? The client advances the unaffected leg first while climbing stairs. A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? Let the client know that, as their nurse, they are available and willing to listen. A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? Clamp the infusion tubing. A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? Ensure that the client wears a surgical mask during transportation throughout the facility. A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? The client's face should be turned toward Mecca. A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? Resolved health conditions A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? Compare the client's pedal pulses bilaterally every 4 hr. A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? Shred the paper in a secure container. A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body? Clean soiled areas of the body. A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? Check the pH of the gastric aspirate A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? "The reduced muscle tone has relaxed the jaw muscles." A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)? Apply thromboembolic stockings. A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? Provide privacy for the client. A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.) Ensure that the client is wearing nonskid slippers. Place the client in a room near the nurses' station. Reinforce teaching about how to use the call bell. A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? A stage 3 pressure injury on the coccyx A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? Drain urine from the tubing before ambulation A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? Attend an exercise program A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? An 18-year-old client who has acute appendicitis A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever? Administer acetaminophen A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.) Cool extremities Orthostatic hypotension Flat neck veins A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? Speak with the client about their condition after visitors have left. A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? "I see that you are angry. Let's sit down and talk." A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? Administer an analgesic 30 min before starting the procedure. A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? The client reports urinary incontinence. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? Mild soap A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot? Dorsalis pedis A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? Precontemplation A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? Pad bony prominences on the wrist A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? BUN 8mg/dl A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? Urine output of 200 mL over 8 hr A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? Place feet apart with the foot nearest the head of the client's bed in front of the other foot. A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse? A client who has a pulse rate of 110/min A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? Remove polish from the client's fingernail before applying the oximetry probe. A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? "The living will directs my medical care when I am unable to make decisions." A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Assist a client to get out of bed after a breathing treatment. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? Autonomy A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a lowpotassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? 1 cup of applesauce A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? Positive Chvostek's sign A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? Donning a mask to measure the vital signs of a client who has pertussis A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? beneficence A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? Internally rotate the client's hips by using a trochanter roll A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Provide handouts written in the client's primary language. A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? Flashing smoke alarm A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching? "This can help prevent pneumonia." A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about agerelated changes? Circulation becomes less efficient with age. A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? Assign the client to a negative-pressure airflow room. A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take? Compare the medications the provider has prescribed with the client's medications from home. A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? Document the client's refusal of the treatment. A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? Compare the label of the medication container with the medication administration record three times. A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? "We will keep her room cool to help her breathe better." A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.) 1820 mL A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? "When I look at myself in the mirror, I don't know if I can go on." A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? Young adults should receive a dental assessment every 6 months. A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? Ask the client close-ended questions. A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? "I will be sure to keep the crutch tips dry."