ATI RN FUNDAMENTALS PROCTORED EXAM VERSION 1 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. Install bath rails & grab bars in bathrooms B. W ear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home B, C, D Rational: A is recommended for older adults and E as well for risk of falls lOMoAR cPSD|6457222 lOMoAR cPSD|6457222 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. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio A, B, C Rational: D is not for after 18 months of age and polio is also given as a child and not usually beyond 18 yrs old 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. Obtain culture specimens before initiating antimicrobials B. Res trict the client's oral fluid intake C. Encourage the client to limit activity & rest D. Allow the client to shiver to dispel excess heat E. Assist the client w/oral hygiene frequently A, C, E Rational: The nurse should prevent shivering & encourage the client to increase fluids. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth 1 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 r eport communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common -source outbreaks A, B, C, E Rational: Not D because endemic disease is already prevalent within a population, so reporting is not necessary 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. Place the client in a room that has ne gative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions B, C, E Rational: Private room w/droplet precautions indicated for this client. The nurse should wear a gown when contamination from body fluids might happen 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. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster D. Herpes zoster lOMoAR cPSD|6457222 Rational: pink body rash=allergic reaction, red circles w/white centers=ringworm, red cheek rash bilaterally=lupus 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. Prodromal B. Incubation C. Convalescence D. Illness D. Illness Rational: specific s/s present is the illness stage A nurse educator is reviewing w/a newly hired nurse the difference in cli nical 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. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate A, B, E Rational: Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an unde rstanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent ca re center." D. "If I am felling stressed, I will remind myself that this is something I should expect." B. "It is important to schedule routine health care visits even if I'm feeling well." Rational: Routine health screenings are important at any age 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. Becoming actively involv ed in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between & being responsible for 2 gener ations C. Devoting a great deal of time to establishing an occupation Rational: Exploring and establishing career options & establishing oneself is important developmental task in a young adult A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the c lient verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father." C. "I don't even know who I am yet, & now I'm supposed to know what to do."
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