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NGN ATI PN FUNDAMENTALS LATEST TEST BANK REAL EXAM 300+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES|PN FUNDAMENTALS ATI PROCTORED EXAM 2023|AGRADE15,21 €
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NGN ATI PN FUNDAMENTALS LATEST TEST BANK REAL EXAM 300+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES|PN FUNDAMENTALS ATI PROCTORED EXAM 2023 |AGRADE A nurse is assisting with the admission of an older adult client to an acute care facility. The clien t states that they are afraid to go to sleep, fearing they will not wake up. Which of the following therapeutic response the nurse should make? a. "I will have the nursing staff check on you frequently during the night shift" b. "You are right to be afrai d. This place is new to you" c. "I will give you your prescribed sleep medication to help you fall asleep" d. "describe your concerns about sleeping to me" - ...ANSWER..."Describe your concerns about sleeping to me." RATIONALE This statement is open -ended and allows for further communication. This addresses the client's concerns and builds trust. A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask? a. "what types of foods have you been eating?" b. "are you using stool softeners or laxatives?" c. "have you been passing gas?" d. "have you had small liquid stools?" - ...ANSWER..."Have you had small liquid stools." RATIONALE Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Therefore, the first question for the nurse to ask is if the client has had any small liquid s tools, which can indicate that there is seepage of liquid feces around the impacted mass. -Flatus can be present even if the client has an impaction; however, there is another question the nurse should ask first. -The nurse should know what treatments the client might be using at home; however, there is another question the nurse should ask first. -The nurse should know what foods the client is eating to determine if they need to modify their diet; however, there is another question the nurse should ask fi rst. A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? a. client reports voiding three times during the night b. client reports burning and discomfort with urination c. client's WBC is 11,000/mm3 d. the client's output was 60 ml for the past 3 hours - ...ANSWER...The client's output was 60 mL for the past 3 hours. RATIONALE When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function. A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? a. the client reports incisional pain as 7 on a scale of 0 to 10 b. the client reports increased nausea and chills c. the client has an oral temperature of 38.5 degrees Celsius (101.3 Fahrenheit) d. the client has tenderness and warmth in their calf - ...ANSWER...The client has tenderness and warmth in their calf. RATIONALE: When using the airway, breathing, circulat ion approach to client care, the nurse should determine that the priority finding to report is tenderness and warmth in the client's calf, which can indicate the presence of a thrombus. If it moves from the vein to the heart, brain, or lungs, it can cause life-threatening complications. A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? a. "do you receive holy communio n?" b. "do you follow a kosher diet?" c. "do you consume pork products? d. "do you oppose receiving a blood transfusion if it is needed?" - ...ANSWER..."Do you consume pork products?" Some clients who practice Islam do not consume pork or alcohol. A nurs e is planning to administer medication to a client who has Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? a. clean hands with an alcohol -based hand rub immediately after removing gloves b. remove the cover gown in the client's room after providing care c. place the client in a room with negative -pressure airflow d. wear a mask when administering oral medications to the client - ...ANSWER...Remove the cov er gown in the client's room after providing care. RATIONALE: The nurse should initiate contact precautions for clients who have a C. difficile infection. Contact precautions include the removal of the cover gown and other personal protective equipment in side the client's room to prevent the spread of infection. -Alcohol -based hand rubs are not effective against C. difficile; therefore, the nurse should use soap and water to clean hands after providing care. -Clients who have a C. difficile infection requ ire contact precautions. A negative -
pressure environment is a requirement for clients who are placed in airborne precautions. -Clients who have a C. difficile infection require contact precautions. Therefore, the nurse should wear gloves and a gown when gi ving direct care to the client. A mask is a requirement when caring for clients who are placed in droplet precautions. A nurse in a long -term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions s hould the nurse take? a. sit beside the client b. speak slowly and loudly to the client c. dim the lights on the client's room d. choose a private room for the interview - ...ANSWER...Choose a private room for the interview. RATIONALE: The nurse should u se a private room, which will minimize background noise so the client is able to hear what the nurse is saying. A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take ? a. measure the client's gastric residual before each feeding b. change the bag and tubing every 24 hr. c. document intake and output d. flush the tubing with 30 ml of water after each feeding - ...ANSWER...Measure the client's gastric residual before ea ch feeding. RATIONALE: When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take. A nurse is caring for a client who has an indwelling urinary cath eter. Which of the following actions should the nurse take? a. clean the perineal area at least once a day b. empty the drainage bag when it is three/fourths full c. flush the catheter with sterile water daily d. disconnect the drainage bag when emptying and measuring urine - ...ANSWER...A. Clean the perineal area at least once a day. The nurse should clean the perineal area at least once a day to reduce the risk for infection. A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? a. lift the staple remover when squeezing the handle b. avoid completely closing the handle after squeezing c. expect the staples to bend at each outer side of the staple d. remove the staple from the skin after b oth sides are visible - ...ANSWER...Remove the staple from the skin after both sides are visible. The nurse should remove the staple from the skin after both sides of the staple are visible, which indicates proper dislodgement of the staple and prevents p ulling on the skin around the incision, which can cause needless discomfort. A nurse is contributing to the plan of care for four patients. For which of the following clients should the nurse initiate airborne precations? a. a client who has pneumonia b. a client who has measles c. a client who has pertussis d. a client who has methicillin -resistant Staphylococcus aureus (MRSA) - ...ANSWER...A client who has measles. The nurse should initiate airborne precautions for a client who has measles. -The nurse should initiate droplet precautions for a client who has pneumonia -The nurse should initiate droplet precautions for a client who has pertussis. -The nurse should initiate contact precautions for a client who has MRSA. A nurse is assisting with the admi ssion of a client to a medical -surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? a. heart rate 89/min b. pink mucous membranes c. pallor with scaly skin d. body mass index 23 - ...ANSWER...Pallor with scaly skin. The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of sun -exposed skin in clients who are well -nourished. -A heart rate of 89/min is within the expected reference range of 60 to 100/min for an adult client. This finding does not indicate malnutrition. -Red, swollen, and inflamed gums are an indication of malnutrition. Pink mucous membranes are an expected finding in well -nouri shed clients. -A body mass index below 18.5 indicates malnutrition.
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