foundations 2 ati questions

a nurse is caring for a patient who acquired an infection after touching a faucet that an infected person has touchec. which of the following links in the chain of infection does the faucet represent

a nurse is caring for a patient who acquired an infection after touching a faucet that an infected person has touchec. which of the following links in the chain of infection does the faucet represent

reservior

a nurse is assisting with teaching a newly licensed nurse about surgical asepsis. which of teh following statements should the nurse make

remove nail polish on your fingers if it is chipped

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?

bacteria

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?

open the first flap on the sterile package away from their body

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?

Report needlestick injuries to the nursing supervisor.

A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?

convalescence

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?

soap and water

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?

Swab the back of the client's pharyngeal wall.

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?

contact

A nurse is planning to admit a client who has respiratory syncytial virus. Which of the following precautions should the nurse plan to implement?

contact

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

turns off the faucet with a towel

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?

droplet

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?

Gloves should be removed from the inside out.

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?

dropelt

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?

The door to the AIIR should remain closed.

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection?

susceptible host

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?

Try to use alternatives before inserting indwelling urinary catheters.

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?

c reactive prot4ein

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?

gloves

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?

After changing a dressing on the client and before documenting findings on a computer

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?

airborne

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?

Apply chlorhexidine and ethanol to the hands.

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?

airborne

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?

place the client in a private room

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?

prodromal

A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following amounts represents the client's intake over the last 4 hr?

1120

A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make?

a+, ab-, ab+, a-

A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client?

increase carbon dioxide level

A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider?

decrease in level of consciusness

A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

The nurse selects 0.45% sodium chloride to use to prime the tubing.

A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (Select all that apply.)

decreased kdiney function

decreased thirst response

decreased total body fluid

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor?

infection at access site

A nurse has completed collecting data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next?

planning

A nurse is reviewing a client's latest arterial blood gas (ABG) report. Which of the following values should the nurse identify as the priority to report to the provider?

PaO2 76 mm Hg

A nurse is preparing to administer 4,200 mL of intravenous fluids to a client to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

175 mL

A nurse on a pediatric floor is reinforcing teaching with a newly licensed nurse about IV therapy. Which of the following information should the nurse include?

Perform range of motion exercises on the extremity containing the IV site.

A nurse is assisting in the care for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheters should the nurse recommend using?

22 gauge

A nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications?

circulatory overload

A nurse is reviewing laboratory results for a client and notes the following arterial blood gas (ABG) values: pH 7.31, PaCO2 49 mm Hg, and HCO3- 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances?

respiratory acidosis

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia?

A client who has vomited four times during the last 8 hr.

A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make?

You can receive a blood donation from donors with type O- and type O+ blood

A nurse is caring for a client who has the following arterial blood gas (ABG) values: pH 7.44, PaCO2 37 mm Hg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following?

acid base balance

A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.)

The client states their muscle spasms are absent.

The client denies being confused.

A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan for the blood to infuse over which of the following lengths of time?

4 hours

A nurse is assisting an RN who is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take?

Apply a blood pressure cuff set to 30 mm Hg

A nurse is reviewing the arterial blood gas (ABG) values for a client and notes the following results: pH 7.49, PaCO2 39 mm Hg, and HCO3- 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances?

metabolic alkalosis

A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate?

0.9% sodium chloride solution

A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider?

Magnesium 3 mEq/L

A nurse is assisting in the care of a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first?

Elevate the head of the client's bed

A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process?

evaluation

A nurse is preparing to administer 1,950 mL of 0.45% sodium chloride IV to infuse over 13 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

150

A nurse is collecting data from a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid or electrolyte imbalance?

The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day.

A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing metabolic acidosis. Which of the following ABG values should the nurse expect? (Select all that apply.)

. HCO3- 19 mEq

pH 7.29
PaCO2 35 mm Hg

A nurse is assisting in the care of a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take?

Verify the unit of blood with another nurse.

A nurse is caring for a client who states, "My doctor said I should have and EMG (electromyograph). What is that?" Which fo the following responses should the nurse make?

"It is a test that determines if there is nerve damage affecting a muscle."

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? SATA

walking cane

walker

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? SATA

difficulty maintaining attention

agitation

hallucination

rambling speech

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?

glaucoma

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia?

difficulty problem solving

A nurse is caring for a middle-adult client who asks about expected age-related changes. Which fo the following sensory changes should the nurse include as age-related change?

presbyopia

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII?

whisper something in one ear while occluding the other ear

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? SATA

- Asks for questions to be repeated
- Withdraws from social activities
- Describes sounds as being muffled

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?

Availability of aids to enhance vision.

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?

hearing loss

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following decreases with age? SATA

sour

bitter

salty

A nurse is caring for a client who is scheduled for an otoacoustic emission (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make?

"You will have a small probe placed in your ear canal during the test."

A nurse is reviewing the process of how a refraction assessment is preformed with a client. Which of the following statements should the nurse make?

"This test is performed using lenses of various prescription strengths."

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss.

A nurse is proving care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?

Keep the client's environment free from clutter.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?

Check the client's visual acuity using a Snellen chart.

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? SATA

- Ensure the client wears their hearing aids.
- Use a sign language interpreter.
- Communicate using paper and pen.
- Face the client when speaking.

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?

"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following informations should the nurse include?

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? SATA

- Trauma to the outer ear
- Inflammation
- Cerumen buildup
- Otitis media

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? SATA

- Loop diuretics
- NSAIDS
- Aminoglycoside antibiotics

The nurse is reviewing the medical record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

Alzheimer's disease.

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? SATA

- Inspect the feet every day.
- Wear closed-toe shoes.
- Manage glucose levels.

A charge nurse is discussing hearing test with a newly licensed nurse. Which of the following information should the charge nurse include?

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

braden score of 9

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should report pain at my wound site".

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

"This type of healing begins in the wound bed with the generation of granulation tissue".

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

empty and measure the drainage

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and call for help. Which of the following actions should the nurse take?

Cover the client's wound with a sterile saline dressing

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?

The AP places the client in high-Fowler's position

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is incontinent and taking a prescribed diuretic

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

increased blood glucose

A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

The skin of older adults is thinner and has less subcutaneous padding over bony prominences

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

Flex the client's knees while in bed

A nurse is caring for a client who has dime-sized stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use?

transparent film

A nurse is planning care for an older adult clients who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Tilt the client on their side at 30 degrees

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

hydrogel

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

dehiscence

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

Your staples will be removed in about 2 weeks

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9% sodium chloride

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

The skin assists in the regulation of body temperature

A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

Pressure injury documentation includes location, stage, measurements and condition of the wound bed and any drainage present

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

"I should increase my protein intake."