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NGN ATI PN FUNDAMENTALS WITH NGN 2023 EXAM TEST BANK
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NGN ATI PN FUNDAMENTALS WITH NGN 2023 EXAM TESTBANK
A nurse is caring for a client who has an indwelling urinary catheter. 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 both 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 pulling 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 admission 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-nourished clients.
-A body mass index below 18.5 indicates malnutrition.
A nurse is reinforcing teaching with a client about self-administration of ophthalmic
drops. Which of the following instructions should the nurse include?
a. "you will need to look to the side when putting drops in your eye"
b. "you should put the drops directly in the center of your eyeball"
c. "you should cleanse your eye form the inner to the outer edge prior to putting in
the drops"
d. "you should avoid pressing on the tear duct after putting the drops in your eye -
ANSWER: "You should cleanse your eye from the inner to the outer edge prior to
putting in the drops."
The nurse should instruct the client to cleanse the eye from the inner to the outer
canthus to prevent contamination of the lacrimal duct.
The nurse should instruct the client to look up during instillation of the medication to
help protect the cornea and to reduce blinking.
The nurse should instruct the client to place the drops on the lower conjunctival sac
to protect the cornea.
The nurse should instruct the client to press on the nasolacrimal duct for 30 seconds
after instillation to prevent systemic absorption of the medication.
A nurse is caring for a client who reports itching 30 min after receiving a newly
prescribed medication. Which of the following data should the nurse document in
the client's medical record?
a. client is itching from medication
b. client states, "I started to itch after taking that medication."
c. it appears the client has a rash from the medication
, d. rash from medication noted - ANSWER: Client states, "I started to itch after taking
that medication."
The nurse should document information using an objective description, putting the
client's exact words in quotation marks.
A nurse manager is reinforcing teaching with a group of newly licensed nurses about
the disclosure of client health information. A nurse can disclose health information
without the client's written permission to which of the following entities?
a. an insurance agency offering a life insurance policy
b. a family member who requests the client's diagnosis
c. a physical therapist who is involved in the client's care
d. an employer completing a pre-employment screening - ANSWER: A physical
therapist who is involved in the client's care.
According to HIPAA guidelines, a nurse is allowed to disclose personal health
information to members of the health care team involved in the client's care.
A nurse is caring for a client who has been vomiting and has diarrhea. Which of the
following findings should the nurse identify as an indication of fluid volume deficit?
a. BUN 18mg/dl
b. a thready pulse
c. hemoglobin 15 g/dl
d. prominent neck veins - ANSWER: A thready pulse
A client who has fluid volume deficit will have thready peripheral pulses.
-A BUN above 20 mg/dL indicates an extracellular fluid volume deficit. This finding is
within the expected reference range of 10 to 20 mg/dL.
-The nurse should identify that a hemoglobin level of 15 g/dL is within the expected
reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females. An
increased hemoglobin level indicates that the client can be experiencing
dehydration, congenital heart disease, or COPD, while decreased levels can indicate
anemia, cirrhosis, or hemorrhage.
-With a fluid volume deficit, the client's neck veins are flat. With a fluid volume
excess, they are full and visible when the client is in a sitting position.
A nurse in a provider's office is providing care for a client who has minimal exposure
to sunlight. Which of the following interventions should the nurse recommend?
a. reduce intake of calcium-rich foods
b. use sunscreen with skin protection factor (SPF) of 8
c. take vitamin D supplements
d. use tanning bed 2 hr weekly - ANSWER: Take Vitamin D supplements .
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