ATI Exit Exam PN 2023

1. A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information? a. Federal legislation dictates the legal guidelines for advance directives b. Advance directives include instruction for resolving financial matters c. Advance directives include a living well d. My medical record should not include c. Advance directives include a living well 2. A nurse on a medical surgical unit is assisting with the admission of a client who has advanced lung cancer. Which of the following actions regarding advance directives should the nurse take? a. Ensure that an attorney has received the client's advance directives b. Document the client's decision about end-of-life care in the medical record c. Tell the client that a family member should serve as a health care surrogate d. Contact the facility's risk manager to verify if the client has a living will b. Document the client's decision about end-of-life care in the medical record #3. A nurse is reinforcing teaching with a client about advance directives and a healthcare proxy which of the following client statements and the kids and understanding of the teaching I do not need to name a relative as my designee in my health care proxy 4. A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching? "I know I can change my advance directives if I need to in the future."5. A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Supplement spoken language with pictures. Or review the facility policy about the use of an interpreter 6. A nurse is caring for a client who speaks a different language than the nurse. The clients partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the ff actions should the nurse take? a. Discharge the client and notify the health care provider b. Request the services of an interpreter to determine the clients wishes c. Have the client's partner sign an AMA form d. Ask the partner to reiterate the consequences of leaving AMA to the client b. Request the services of an interpreter to determine the clients wishes 7. A nurse at long term care facility is reviewing the plan of care who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel? a. Evaluate the need client b. Assist the client with range of motion exercises of the hands c. Determine the circulation status d. Instruct the client's family about purpose mitten restraint b. Assist the client with range of motion exercises of the hands 8.A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client? a. Monitor the client's range of motion every 60 min. b. Plan to remove the restraints as soon as the clients is calm c. Offer the clients nutritious snack every 4 hr. d. Ensure that the procedure has signed a prescription for restrain within 48 hr.b. Plan to remove the restraints as soon as the clients is calm 9. A nurse in a mental health facility receives a change of shift report on 4 clients. Which of the following clients should the nurse plan to assess first? 1. A client placed in restraints for aggressive behavior 2. A new limited client presents history of 4.5kg weight loss in the past two months 3. Client is receiving a PRN dose of haloperidol two hours ago for increased anxiety 4. Client will receive his first ECT treatment today 1. A client placed in restraints for aggressive behavior 10. A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take? -Check the client's status every hour. -Document the client's behavior leading to the initiation of restraints. -Obtain written consent by the client for the placement of the restraints. -Release the client's restraints every 4 hr. Check the client's status every hour. 11. A nurse is caring of a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take? a. Remove the restraints from the client's wrists every 2 hr. b. Fasten the restrains ties to the bed's side rail c. Contact the provide within 48 hr. to obtain a prescription for the restrain d. Check that one finger will fit between the client's wrist and the restraints a. Remove the restraints from the client's wrists every 2 hr. 12. nurse delegates a task to an AP and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?1. Report the AP to the risk manager13. A nurse is preparing to delegate client care to an assistive personnel AP. Which of the following information should the nurse verify prior to delegation? a. The AP's years of experience b. The client's length of facility stay c. The client's age d. The AP's job description d. The AP's job description 14. A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift which of the following tasks the nurse delegate to assistive personnel (select all that apply) Measure vital signs for a client who requires contact precaution, record urine output for a client who has a super pubic catheter, trees for a client who is receiving radiation therapy to radiology ***15. A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse? a. Benzodiazepines are administered every 4hr b. Supplemental oxygen in use c. A family member remains at the client's bedside 24 hr. each day d. An assistive personnel is encouraging intake of oral fluids a. Benzodiazepines are administered every 4hr