ATI Fundamentals Retake
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 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 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.
A nurse is preparing to delegate client care tasks to an assistive personnel(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 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 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.
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.
,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.
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.
, The nurse is providing discharge teaching for a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions 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
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.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the
nurse take? (select all that apply)
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 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 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.
A nurse is preparing to delegate client care tasks to an assistive personnel(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 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 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.
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.
,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.
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.
, The nurse is providing discharge teaching for a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions 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
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.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the
nurse take? (select all that apply)
