Chapter 1 correct answers Health care delivery systems
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.)
A. Home health care
B. Rehabilitation facilities
C. Diagnosti...
ATI RN Fundamentals Practice
A nurse is caring for a client who reports pain. When documenting the
quality of
client's theon an initial pain assessment, the nurse should record
pain
which of the
following client
statements?
"I am having mild
pain"
"The pain is like a dull ache in my
stomach"
"I notice that the pain gets worse
after pain
"The I eat"makes me feel nauseous" correct answers "The pain is like a dull
ache in my
stomach
"
A client in non ambulatory notifies the nurse that his trash can is on fire.
After the the
confirms nursepresence of the fire, which of the following actions should the
nurse
next take
?
Activate the emergency fire
alarm
Extinguish the
fire
Evacuate the
client
Confine the fire correct answers Evacuate
the client
A nurse is completing an admission assessment for a client who reports
vomiting for
diarrhea andthe past 3 days. Which of the following findings should the
nursevein
Neck expect?
distention
Urine specific gravity
1.010
Rapid Heart
rate
Blood pressure 144/82 mmHg correct answers Rapid
heart rate
A nurse has accepted a verbal prescription for "thee tenths of a
milligram of IV stat" for a client who has myxedema coma. How should
levothyroxine
the nurse the dosage of this medication in the client's
transcribe
medical record?
.3
mg
0.3
mg
0.30
mg
3/10 mg correct answers
0.3 mg
A nurse is preparing a heparin infusion for a client who was admitted to the
facility
deep withthrombosis. The prescription reads: 25,000 units of heparin in
vein
0.9% sodium
chloride 250 ml to infuse at 800 units/hour. At what rate should the
nurse setpump?
infusion the correct answers 8
ml/hour
A nurse is caring for a client who has a prescription for wound irrigation.
Which of the
following actions should the nurse
take?
Wear sterile gloves when removing the old
dressing
Warm the irrigation solution to 40.5 C
(105 F)
,Cleanse the wound from the center
outward
Use a 20 ml syringe to irrigate the wound correct answers Cleanse the
wound from the
center
outward
A nurse is caring for a client who is receiving fluid through a peripheral
IV catheter.
Which of the following findings at the IV site should the nurse identify as
indicating
infiltratio
n?
Purulent
exudate
Warmt
h
Skin
blanching
Bleeding correct answers Skin
blanching
A nurse is teaching a client whose left leg is in a cast about using crutches.
Which of the
following statements should the nurse identify as an indication
that the clientthe
understands
teaching?
"When descending the stairs, I will first shift my weight to my
right leg" place my crutches 12 inches in front and to the side of
"I should
eachI sit
"As foot"
down, I will hold one crutch in each
hand"
"I will make sure the shoulder rests are snug against my armpits"
correct descending
"When answers the stairs, I will first shift my weight to my
right leg"
A nurse is caring for a client who has an NG tube and is receiving
intermittent
through feedings
an open system. Which of the following actions should the nurse
take first?
Rinse the feeding back with water between
feedings
Tell the client to keep the head of the bed elevated at least
30 degrees
Make sure the enteral formula is at room
temperature
Wipe the top of the formula can with alcohol correct answers Tell the client
to keep
head of the
the bed elevated at least 30
degrees
A nurse is reviewing a client's medication prescription that reads,
"digoxin
mouth every
0.25 day".
by Which of the following components of the prescription
shouldverify
nurse the with the
provider?
Medication
name
Route of
administration
Medication
dose
Frequency of administration correct answers
Medication dose
A nurse is caring for a client who has recently started using a behind the
ear hearing
aid. Which of the following statements should the nurse identify as an
indication
client that the the use of this assistive
understands
device?
"This type of hearing aid does not allow for fine tuning of
volume"
"I shouldn't have trouble keeping the hearing aid in place during
exercise"
"I expect to hear a whistling sound when I first insert the
hearing
"I will beaid"
sure to remove my hearing aid before taking a shower" correct
answers
be sure to "I remove
will my hearing aid before taking a
shower"
, A nurse enters a client's room and finds her on the floor. The client's
roommate
that reports
the client was trying to get out of bed and fell over the side rail onto the
floor.
of theWhich
following statements should the nurse document about this
incident?
"Incident report
completed"
"Client climbed over the side
rails"
"Client found lying on the
floor"
"Client was trying to get out of bed" correct answers "Client found lying
on the floor"
A nurse on a medical unit is preparing to discharge a client to home.
Which of the
following actions should the nurse take as part of the medication
reconciliation
Seal process?
unused medications from the facility in a
plastic bag
Evaluate the client's ability to self administer
medications
Report an identified discrepancy to The Joint
Commission
Compare prescriptions with medications the client received while at the
facility correct
answers Compare prescriptions with medications the client received while
at the facility
A nurse is caring for a client who requires an informed consent for a surgical
procedure.
Which of the following actions is the nurse's
responsibility?
Describe the procedure to the
client
Witness the client's signature on the
consentthe
Inform formclient of alternatives to the
procedure
Tell the client which team members will assist with the procedure
correct answers
Witness the client's signature on the
consent form
A nurse is planning an educational program for a group of older adults at a
senior living
center. Which of the following recommendations should the nurse
include?
"You should have an eye examination every 2
years"
"You should receive a tetanus booster every 5
years"
"You should receive a shingles vaccine when you are 70
yearsshould
"You old" receive a pneumococcal vaccine when you are 65 years
old" correct
answers "You should receive a pneumococcal vaccine when you are 65
years old"
A nurse is caring for a client who is refusing a blood transfusion for
religious
The reasons.
client's partner wants the client to have the blood transfusion.
Which of the
following actions should the nurse
take?
Ask the client to consider a direct
Withhold the blood
donation
transfusion
Request a consultation with the ethics
committee
Ask the client's family to intervene correct answers Withhold the blood
transfusion
A nurse is admitting a client who has rubella. Which of the
following types
transmission of precautions should the nurse
based
initiate?
drople
tairborn
e
contac
tprotective environment correct answers
droplet
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