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1. A charge nurse is discussing the responsibility of nurses caring for clients
who have Clostridium difficile infection. Which of the following information
should the nurse include in the teaching?
a. assign the client to a room with a negative airflow system
b. use alcohol-based hand sanitizer when leaving the client's room
c. clean contaminated surfaces in the client's room with a phenol solution
d. have family members wear a gown and gloves when visiting: d. have family
members wear a gown and gloves when visiting
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. 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.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.Nurses are responsible
for ensuring that family members wear a gown and gloves to prevent the transmis-
sion of Clostridium difficile spores. Staff must also wear gowns and gloves.
2. 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 info is the
priority for the nurse to provide?
a. admitting diagnosis
b. breath sounds
c. body temperature
d. diagnostic test results: b. breath sounds
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. 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. Body temperature
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. Knowing diagnostic test results is essential for planning care and following
critical pathways; however, other information is the nurse's priority to provide.
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3. A nurse is preparing to delegate client care tasks to an assistive person-
nel(AP). Which of the following tasks should the nurse delegate?
a. ambulating a client who is postop
b. inserting an indwelling urinary catheter for a client
c. demonstrating the use of an incentive spirometer to a client
d. confirming that a client's pain has decreased after receiving an analgesic: a.
ambulating a client who is postop
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 clientIndwelling urinary catheter inser-
tion 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 clientClient 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 analgesicEvaluating
a client's pain level requires advanced nursing judgment and is outside the range of
function of an AP.
4. 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?
a. "incident report completed"
b. "client climbed over the side rails"
c. "client found lying on the floor"
d. "client was trying to get out of bed": c. "client found lying on the floor"
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."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." 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 was trying to get out of bed."Unless the nurse witnessed the client trying to
get out of bed, this statement is not an objective account of the nurse's findings.
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5. A nurse is caring for a client who has a prescription for wound irrigation.
Which of the following actions should the nurse take?
a. wear sterile gloves when removing the old dressing
b. warm the irrigation solution to 40.5(105 degrees farenheit)
c. cleanse the wound from the center outward
d. use a 20 mL syringe to irrigate the wound.: c. cleanse the wound from the
center outward
The nurse should wear clean gloves to remove the old dressing.
Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the irrigation
solution to body temperature.
Cleanse the wound from the center outward. The nurse should clean the wound from
the center outward to prevent introduction of micro-organisms from the outer skin
surface.
Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe to
irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective
amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types
of transmission based precautions should the nurse initiate?
a. droplet
b. airborne
c. contact
d. protective environment: a. droplet
Droplet precautions are a requirement for clients who have infections that spread via
droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella,
meningococcal pneumonia, and streptococcal pharyngitis.
Airborne precautions are a requirement for clients who have infections that spread
via droplet nuclei that are smaller than 5 microns in diameter, including varicella,
tuberculosis, and measles.
Contact precautions are a requirement for clients who have infections that spread
via direct contact with another person or contact with the environment, including
vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and
scabies.
Protective environment Clients who have a compromised immune system, such as
those who have had an allogeneic hematopoietic stem cell transplant, require a
protective environment.
7. The nurse is providing discharge teaching for a client who has a new pre-
scription for a home oxygen concentrator. Which of the following instructions
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should the nurse provide to the client and his family? select all that apply.
a. check the cord routinely for frays and tearing
b. keep the unit at least 1.2 m (4 feet) away from a gas stove
c. consider purchasing a generator for power backup
d. observe for signs of hypoxia
d. select synthetic clothing and bedding: a,c,d
Check the cord routinely for frays or tearing is correct. Oxygen concentrators require
electrical power. Safe use of this delivery system includes assessing the electrical
function of the device; therefore, the nurse should instruct the client to routinely
check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas
stove is incorrect. Safe use of home oxygen equipment includes keeping the unit
at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas
stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing
a generator for power backup is correct. Loss of electricity prevents the oxygen
concentrator from functioning and could deprive the client of necessary oxygen. The
nurse should also instruct the family to have the client placed on their municipality's
priority list for restoring power after an outage occurs.Observe for signs of hypoxia
is correct. The nurse should instruct the family to observe for
8. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the
following should the nurse plan to document on the client's intake and output
record as 120 mL of fluid?
a. 2 cups of soup
b. 1 quart of water
c. 8 oz of ice chips
d. 6 oz of tea: c. 8 oz of ice chips
2 cups of soup. The nurse should understand that 2 cups of soup are equivalent to
480 mL of fluid.
1 quart of water. The nurse should understand that 1 quart of water is equivalent to
960 to 1,000 mL of fluid.
8 oz of ice chips. The nurse should document half of the volume of ice chips when
calculating fluid intake to account for the air in between the chips. The nurse should
understand that 4 oz of liquid water is equal to 120 mL of fluid.
6 oz of tea. The nurse should understand that 6 oz of tea is equal to 180 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following
actions should the nurse take? (select all that apply)
a. place the client in a room with negative airflow pressure
b. wear gloves when assisting the client with oral care
Study online at https://quizlet.com/_e1zdhu
1. A charge nurse is discussing the responsibility of nurses caring for clients
who have Clostridium difficile infection. Which of the following information
should the nurse include in the teaching?
a. assign the client to a room with a negative airflow system
b. use alcohol-based hand sanitizer when leaving the client's room
c. clean contaminated surfaces in the client's room with a phenol solution
d. have family members wear a gown and gloves when visiting: d. have family
members wear a gown and gloves when visiting
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. 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.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.Nurses are responsible
for ensuring that family members wear a gown and gloves to prevent the transmis-
sion of Clostridium difficile spores. Staff must also wear gowns and gloves.
2. 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 info is the
priority for the nurse to provide?
a. admitting diagnosis
b. breath sounds
c. body temperature
d. diagnostic test results: b. breath sounds
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. 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. Body temperature
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. Knowing diagnostic test results is essential for planning care and following
critical pathways; however, other information is the nurse's priority to provide.
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
3. A nurse is preparing to delegate client care tasks to an assistive person-
nel(AP). Which of the following tasks should the nurse delegate?
a. ambulating a client who is postop
b. inserting an indwelling urinary catheter for a client
c. demonstrating the use of an incentive spirometer to a client
d. confirming that a client's pain has decreased after receiving an analgesic: a.
ambulating a client who is postop
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 clientIndwelling urinary catheter inser-
tion 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 clientClient 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 analgesicEvaluating
a client's pain level requires advanced nursing judgment and is outside the range of
function of an AP.
4. 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?
a. "incident report completed"
b. "client climbed over the side rails"
c. "client found lying on the floor"
d. "client was trying to get out of bed": c. "client found lying on the floor"
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."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." 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 was trying to get out of bed."Unless the nurse witnessed the client trying to
get out of bed, this statement is not an objective account of the nurse's findings.
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
5. A nurse is caring for a client who has a prescription for wound irrigation.
Which of the following actions should the nurse take?
a. wear sterile gloves when removing the old dressing
b. warm the irrigation solution to 40.5(105 degrees farenheit)
c. cleanse the wound from the center outward
d. use a 20 mL syringe to irrigate the wound.: c. cleanse the wound from the
center outward
The nurse should wear clean gloves to remove the old dressing.
Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the irrigation
solution to body temperature.
Cleanse the wound from the center outward. The nurse should clean the wound from
the center outward to prevent introduction of micro-organisms from the outer skin
surface.
Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe to
irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective
amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types
of transmission based precautions should the nurse initiate?
a. droplet
b. airborne
c. contact
d. protective environment: a. droplet
Droplet precautions are a requirement for clients who have infections that spread via
droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella,
meningococcal pneumonia, and streptococcal pharyngitis.
Airborne precautions are a requirement for clients who have infections that spread
via droplet nuclei that are smaller than 5 microns in diameter, including varicella,
tuberculosis, and measles.
Contact precautions are a requirement for clients who have infections that spread
via direct contact with another person or contact with the environment, including
vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and
scabies.
Protective environment Clients who have a compromised immune system, such as
those who have had an allogeneic hematopoietic stem cell transplant, require a
protective environment.
7. The nurse is providing discharge teaching for a client who has a new pre-
scription for a home oxygen concentrator. Which of the following instructions
, ATI Fundamentals Retake
Study online at https://quizlet.com/_e1zdhu
should the nurse provide to the client and his family? select all that apply.
a. check the cord routinely for frays and tearing
b. keep the unit at least 1.2 m (4 feet) away from a gas stove
c. consider purchasing a generator for power backup
d. observe for signs of hypoxia
d. select synthetic clothing and bedding: a,c,d
Check the cord routinely for frays or tearing is correct. Oxygen concentrators require
electrical power. Safe use of this delivery system includes assessing the electrical
function of the device; therefore, the nurse should instruct the client to routinely
check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas
stove is incorrect. Safe use of home oxygen equipment includes keeping the unit
at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas
stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing
a generator for power backup is correct. Loss of electricity prevents the oxygen
concentrator from functioning and could deprive the client of necessary oxygen. The
nurse should also instruct the family to have the client placed on their municipality's
priority list for restoring power after an outage occurs.Observe for signs of hypoxia
is correct. The nurse should instruct the family to observe for
8. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the
following should the nurse plan to document on the client's intake and output
record as 120 mL of fluid?
a. 2 cups of soup
b. 1 quart of water
c. 8 oz of ice chips
d. 6 oz of tea: c. 8 oz of ice chips
2 cups of soup. The nurse should understand that 2 cups of soup are equivalent to
480 mL of fluid.
1 quart of water. The nurse should understand that 1 quart of water is equivalent to
960 to 1,000 mL of fluid.
8 oz of ice chips. The nurse should document half of the volume of ice chips when
calculating fluid intake to account for the air in between the chips. The nurse should
understand that 4 oz of liquid water is equal to 120 mL of fluid.
6 oz of tea. The nurse should understand that 6 oz of tea is equal to 180 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following
actions should the nurse take? (select all that apply)
a. place the client in a room with negative airflow pressure
b. wear gloves when assisting the client with oral care
