B- Ati Fundementals

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Support the client's feet with foot boots.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Performance of a paracentesis

A nurse is caring for a client who is at risk for pressure ulcers. Which of the following findings should the nurse report to the primary care provider?

Albumin level of 2.5 g/dL

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Pad bony prominences on the wrist.

A nurse is caring for a client who is refusing to take their prescribed medication. Which of the following actions should the nurse take?

Document the client's refusal of the medication.

A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?

"You should cover your mouth with a tissue when you cough."

A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide?

"Provide mouth care to them at least every 2 hours."

A nurse is observing a client who is learning to walk with crutches. Which of the following observations should the nurse identify as an indication that the client understands how to use the crutches?

The top of each crutch is three finger widths (2 in) below the axilla.

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?

"When lifting a heavy object, keep it close to your body."

A nurse is assisting with planning an educational seminar for a group of clients at a community center about the expected physical changes associated with aging. Which of the following changes should the nurse instruct the clients to expect?

Decreased cough reflex.

A nurse is caring for a client who is immobile and incontinent of urine. Which of the following actions should the nurse take to maintain skin integrity?

Apply a moisture barrier ointment to the client's perineum. 

A nurse is assisting with the care of a client who will be placed on continuous oxygen therapy with a concentrator when discharged. Which of the following actions is the priority for the nurse?

Collect data about the client's home environment 

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

Latex

A nurse is reviewing the medical record of a female client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

BUN 8 mg/dL (10 to 20 mg/dL)

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

Beneficence

While monitoring a client for edema of the lower extremities, which of the following actions should the nurse take?

Apply pressure to the skin at the client's ankle.

A nurse is demonstrating the proper technique to care for and clean dentures to a client. Which of the following instructions should the nurse include?

Place a washcloth with 1 inch of water in the bottom of the sink.

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

Providing client information to another nurse at change of shift

A nurse is preparing to administer cephalexin 375 mg PO to a client. The amount available is 250 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7.5mL

0800:

Packed RBCs initiated by the charge nurse through an 18-gauge peripheral IV to infuse over 2 hr.

0815:

Client reports itching and anxiety. Client's face is flushed and has hives.

an allergic reaction/itching

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Clean the perineal area at least once a day.

A nurse is assisting with the insertion of a client's peripheral vascular access device (VAD). Which of the following actions should the nurse take?

Turn the VAD with bevel up before insertion.

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements should the nurse recognize indicates an understanding of the teaching?

"The living will directs my medical care when I am unable to make decisions."

A nurse is assisting with the care of a client who has chronic pain and limited mobility. Which of the following actions should the nurse plan to take first, prior to giving the client a bed bath?

Administer oral pain medication.

A nurse is performing a guaiac test on a client’s stool specimen. Which of the following test results should the nurse identify as indicating a positive finding?

Blue

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

Apply thromboembolic stockings.

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

Ask the client what they already know about meal planning.

A nurse is reinforcing teaching with a client who has a new hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will avoid using hairspray while I have my hearing aid in."

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

"I see that you are angry. Let's sit down and talk."

A nurse is reinforcing teaching about health promotion for an older adult client. Which of the following statements made by the client indicates an understanding of the teaching?

"I will use sunscreen when I am in the sunlight."  

A nurse is caring for a client who has breast cancer and expresses fear about the future. Which of the following responses should the nurse make?

"You seem really afraid. Let's talk more about your feelings."

A nurse is reinforcing teaching with a client who reports frequent constipation. Which of the following statements by the client indicates an understanding of the teaching?

"I will be sure not to skip meals."

A nurse is assisting in the care of a 36-year-old female client who is scheduled for surgery using general anesthesia. The nurse should anticipate an order for which of the following point-of-care tests? 

Urine pregnancy test

A nurse is providing end-of-life care to a client who has terminal cancer. Which of the following actions by the nurse would be best to meet the client's highest hierarchal need?

Provide small meals of foods the client prefers.

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take when removing the catheter?

Withdraw the solution in the balloon.

A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse?

A client who has a pulse rate of 110/min

A nurse is contributing to the plan of care for a client who requires droplet precautions. Which of the following interventions should the nurse recommend for the plan of care?

Wear a mask while measuring the client's vital signs.

A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Provide handouts written in the client's primary language.

A nurse is collecting data from a client during admission to the medical floor. Which of the following data should the nurse document as subjective?

Loss of sensation in feet

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?

Positive Chvostek's sign

A nurse is providing postmortem care to a client. Which of the following actions should the nurse take?

Place the body in a supine position with arms lying at the sides.

A nurse is reinforcing teaching about the use of crutches with a client who is unable to bear weight on one leg. Which of the following client statements should the nurse recognize as an indication the teaching was effective?

"When sitting down in a chair, I need to hold both crutches in one hand."

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.)

Keep the family updated about the client's status

Encourage the family to comb the client's hair

Tell the client's family what to expect as the client's death nears

A nurse is caring for a client who has a Clostridioides difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client?

Mild soap

An assistive personnel (AP) asks a nurse for information about the Health Insurance Portability and Accountability Act (HIPAA). Which of the following information should the nurse give the AP about the purpose of HIPAA? (Select all that apply.)

Mandates protection of the client's confidential health care information

Sets standards for the electronic exchange of health care information

Creates client's right to consent to the disclosure of their protected health information

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Autonomy

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

"Perform muscle relaxation before bedtime."

A nurse is evaluating a client's nutritional status. Which of the following data should the nurse obtain to calculate BMI for the client?

Height and weight

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

Notify the charge nurse of the client's concerns.

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

"Please don't tell my provider, but I am taking my partner's oxycodone."

A nurse is preparing to insert a nasogastric (NG) tube for a client. Which of the following actions should the nurse take?

Ask the client to swallow during insertion.

1120:

34-year-old female is attending the event today to ensure they are current on all health screenings.
Client reports a family history significant for breast cancer (mother and maternal grandmother), coronary artery disease (father and mother, paternal grandparents), and prostate cancer (father and paternal grandfather).
Client reports they had the following screenings:
Pelvic examination and Papanicolaou (Pap) test approximately 9 months ago 
Eye examination approximately 1 year ago
Skin cancer screening 2 years ago
Dental examination 2 weeks ago

1145:

Teaching reinforced regarding recommended screenings 

Complete the following sentence by using the lists of options.

Hypertension

Family History

A nurse is caring for a client who reports difficulty sleeping. Which of the following actions should the nurse take?

Assist the client with a warm bath.

Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Client reports tightness in chest and pain when coughing. Client reports losing (2.3 kg) 5 lb in the last week, has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed.

Which of the following actions should the nurse plan to take when caring for this client?

Select all that apply.

Wear an N95 mask when caring for the client.

Assign the client to a negative-pressure airflow room.

Ensure the client wears a mask when transported off the unit.

0800:
Client is 1 day postoperative following a right knee replacement. Alert and oriented x4. Sequential compression devices in place. Surgical dressing dry and intact. Pedal pulses +2 bilaterally. Client rates pain as an 8 on a scale of 0 to 10. Client states, "It really hurts, how will I be able to do physical therapy?". Addressed client’s concerns and administered prescribed PRN analgesic.
0900:
Assisted client to chair at bedside. Client states pain is now a 3 on a scale of 0 to 10, but they felt, "lightheaded" when standing up. Vital signs obtained.  
1000:
Assisted client back to bed. Dressing dry and intact. Sequential compression devices reapplied. 

After reviewing the findings, which of the following actions should the nurse plan to take?

Select the 3 actions that the nurse should plan to take.

Delegate the application of sequential compression devices to assistive personnel

Administer analgesic prior to planned activities

Assist the client to dangle their legs at the bedside prior to standing