NR 324 ATI Funds Assessment Proctor

ATI RN Fundamentals Proctored Focus Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to a assistive personnel (AP)? A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing pre-op care regarding informed consent? Select all. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all that apply The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all that apply. A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all that apply A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him? A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the inter-professional care team? A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the inter-professional care team may assist the client in understanding the medication's effects? Select all that apply. A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the inter-professional care team? A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all. A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all. A nurse is evaluating a client's neurosensory system. To evaluate stereo-gnosis, she would ask the client to close his eyes & identify which of the following items? A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling? A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles w/some crustings. Which of the following should the nurse suspect? A nurse is caring for a client who reports severe sore throat, pain when swallowing, & swollen lymph nodes. The client is experiencing which of the following stages of infection? A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention? A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. A nurse is reviewing the CDC's immunization recommendations w/a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all. A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following info should the nurse include when explaining the procedure to the client? A nurse is talking w/a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all. While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following problems is the client at risk for developing? A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? A nurse is caring for a client who is postop. Which of the following nursing interventions reduce the risk of thrombus development? Select all. : A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching? To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all that apply. A nurse is assessing the pain level of a client who has come to the ER reporting severe abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following? A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by: A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that: A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the med. Which of the following effects should the nurse anticipate? Select all. A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all. A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all. A nurse is reviewing the reported meds of a client who was recently admitted. The meds include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects? A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk med for the control of seizures. Which of the following statements by the nurse is appropriate? A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the med, which of the following actions is the highest priority? A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer? (round to nearest tenth) A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number) A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (round to nearest whole number) A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention? A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve? A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate her BMI & determine whether this client is obese based on her BMI. . A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? Select all. A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching? A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect? A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique? A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take? A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all. A nurse is working w/a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention? A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all. A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that med. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation? A nurse is assessing a client who has an acute resp. infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A nurse is preparing to preform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all. A provider is discharging a client with a prescription from home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all that apply A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, w/scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all. A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A nursing instructor is reviewing the wound healing process w/a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all. A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera protruding. Which of the following interventions is appropriate? Select all. A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.