Fundamentals ATI exam review 2024

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety?

- An extension cord is secured under a rug
- A toaster is plugged in when not in use
- The water heater is set to 55c (131f)
- The edges of stairs are marked with brightly colored tape

The edges of stairs are marked with brightly colored tape

The nurse should instruct the client to mark edges of stairs with brightly colored tape to alert the client of the steps and reduce the risk of fall.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

-Record the time and length of the seizure
-Restrain the clients extremes
-Place the client in the prone position
-Monitor the clients hemoglobin level

Record the time and length of the seizure

The nurse should monitor the length of time of the seizure to evaluate the type of seizure and determine treatment required.

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (Select all that apply)

-Place the client on round-the-clock surveillance
- Remove objects from the room that the client could use to harm themselves
- Search items brought into the clients room by visitors
- Refrain from asking the client if they intend to harm themselves
- Screen the client for suicidal ideations

Place the client on round the clock surveillance

Remove objects from the room that the client could use to harm themselves

Search items brought into the clients room by visitors

Screen the client for suicidal ideations

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the clients risk of developing a healthcare associated infection?

- Wipe down the clients bedside table with an antiseptic wipe.
- Conduct informal audits of medical records to identify the number of healthcare associated infections
- Perform hand hygiene
Instruct the client on ways to reduce the risk for infection

Perform hand hygiene

According to evidence-based practice, hand hygiene among medical professionals, clients, and visitors is the priority intervention to reduce the risk for the client to develop a healthcare-associated infection.

A nurse is checking a clients allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events?

- Near miss event
- Client safety event
- Adverse event
- Sentinel event

Near miss event

A near-miss event is an error that could have harmed the client which almost occurs, but was caught and avoided. The nurse noted the client had an allergy to the medication prior to administering it, avoiding harm to the client.

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elects for fire to occur? (SATA)

- Carbon dioxide
- Nitrogen
- Cooking oil
- Oxygen
- Heat

Cooking oil

Oxygen

Heat

A nurse is assisting with teaching a class about evidence based protocols established by the CDC to prevent healthcare associated infections (HAIs). Which of the following infections should the nurse include? (SATA)

- Influenza infection
- Catheter associated urinary tract infection
- Mycobacterium tuberculosis infection
- Central line associated bloodstream infection
- Surgical site infection

Catheter associated urinary tract infection

Central line associated bloodstream infection

Surgical site infection

A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include?

- Legitimate absenteeism
- Strict adherence to facility policies
- Consistent adequate work performance
- frequent reports of not being treated fairly

frequent reports of not being treated fairly

The nurse should include that persistent complaining and voicing that they are not being treated fairly is a warning sign for possible future workplace violence by a co-worker.

A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

- The nurse plugs in a sequential compression device with wet hands
- The nurse holds onto the plug to unplug a clients electronic blood pressure machine
- The nurse rolls the clients bed over an electrical cord
- The nurse uses an extension cord to plug in a clients smart infusion pump

The nurse holds onto the plug to unplug a clients electronic blood pressure machine

The nurse should instruct the newly licensed nurse to hold onto the plug, rather than the cord, to unplug electric cords. Pulling on the cord can damage the cord, and result in an electric shock that could injure the nurse or the client.

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include which of the following is a hospital-acquired injury? (SATA)

- Blood transfusion incompatibility
- Wrong site surgery
- Ineffective insulin usage
- Dysphagia following a stroke
- Dehydration due to diarrhea

Blood transfusion incompatibility

Wrong site surgery

Ineffective insulin usage

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (SATA)

- A clients visitor falls in the hallway
- A nurse forgets their computer password
- A client develops an unexpected reaction to a medication
- A clients dentures are lost
- An antibiotic was administered to a client 30 min after the scheduled time

A clients visitor falls in the hallway

A client develops an unexpected reaction to a medication

A clients dentures are lost

A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (SATA)

- The client's full name
- The client's date of birth
- The client's telephone number
- The client's diagnosis
- The client's room number

The client's full name

The client's date of birth

The client's telephone number

A nurse is a assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take?

- Rinse the clients skin with water
- Remove the clients clothing by pulling it over their head
- Dispose of the clients clothing in a single biohazard bag
- Prepare to administer potassium iodide to the client

Rinse the clients skin with water

The nurse should have the client shower to remove the chemical toxin from their skin, hair, and eyes to reduce the effects of exposure.

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (SATA)

- Locks breaks on the client's bed
- Check the maximum weight of the lift bed before using it
- Place the client on the edge of the sling
- Uses the lift without assistance from another team member

Locks breaks on the clients bed

Checks the maximum weight of the lift bed before using it

Performs a safety check before lifting the client

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take?

-Tie the restraints to the side rails on the clients bed
- Remove the restraints with each vital sign check
- Use a square knot to secure the restraints
- Make sure one finger can fit under the restraints

Remove the restraints with each vital sign check

The nurse should remove the restraints and check the client's skin and circulation with each vital sign and at least every 2 hr to monitor for client injury.

A nurse is planning to implement the transforming care at the bedside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan?

- Require nurses to spend 50% of their time at the bedside of clients
- Perform change of shift report at the nurses station
- Complete client round every 4 hr
- Use a standardized communication tool

Use a standardized communication tool

The Transforming Care at the Bedside plan recommends using a standardized communication tool, such as the Identity, Situation, Background, Assessment, Recommendation, and Readback (ISBARR) tool. Using a standardized communication tool enhances communication, which results in improved client outcomes.

A nurse is planning to use the identity, situations, background, assessment, recommendation, read back (ISVARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR?

- The client's admitting diagnosis
- The client's medical history
- The clients laboratory test results
- The clients response to reatement

The clients laboratory test results

General client impression and significant findings such as diagnostic tests, laboratory results, and vital signs are included in the assessment component of the ISBARR communication tool.

A nurse discovers a small sire in a clients room. After removing the client to safety, which of the following actions should the nurse take next?

- Extinguish the fire
- Close the windows in the client's room
- Close the client's door
- Activate the fire alarm

Activate the fire alarm

The greatest risk to this client is injury from a fire. Therefore, the next action the nurse should take is to activate the emergency fire alarm to alert emergency responders to extinguish the fire.

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (SATA)

- Fall history
- Medical diagnosis
- Use of assistive devices
- Mental status
- Do not resuscitate status

Fall history

Medical diagnosis

Use of assistive devices

Mental status

A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (SATA)

- The date the medication was mixed
- The client's age
- The client's room number
- The dose of the mixed medication
- The time the medication was mixed

The date the medication was mixed

The dose of the mixed medication

The time the medication was mixed

A nurse is caring for a client who is postoperative and requests spiritual support. Which of the following statements should the nurse make?

- ''Im not trained in providing spiritual support, but you can call the chaplin.''
- ''Tell me what I can do to help fulfill your need for support.''
- ''Lets talk about this later and focus instead on your wound healing.''
- ''I'm not very spiritual so I will find another nurse who can help you.';

''Tell me what I can do to help fulfill your need for support.''

Clients can obtain spiritual support from many things and people. The only way the nurse can find out what the client needs is to ask, and this is an example of an appropriate, therapeutic response.

A nurse manager is planning an in service about culturally competent care, Which of the following cultural competencies should the manager describe as enabling a nurse to interact with client from other cultures?

- Cultural awareness
- Cultural encounter
- Cultural knowledge
- Cultural desire

Cultural encounter

Cultural encounters allow the nurse interaction with clients from cultures other than the nurse's own.

A nurse is caring for a client who is emotionally distraught. Which of the following uses of touch should the nurse implement to convey caring?

- Briefly holding the client's hand
- A lengthy front-facing hug
- rubbing the client's shoulders
- Sitting beside the client and touching their tjigh

Briefly holding the client's hand

A nurse enters a clients room and finds the client crying. The nurse sits beside the bed in silence. Which of the Swansons five categories of caring behaviors is the nurse demonstrating?

- Knowing
- Being with
- Doing for
- Maintaining belief

Being with

Being with is being physically and emotionally present with the client. Being with does not have to involve any speaking. The nurse in this example is being present and available by sitting beside the bed in silence, allowing space for the client to talk when and if they want to talk.

A nurse is planning an in service for a group of staff nurses about spirtiual care. Which of the following situations should the nurse identify as appropriate for consultation with pastoral staff? (SATA)

- Ethical dilemma
- Terminal illness
- Death of a client
- Financial arrangements
- Hardship

Ethical dilemma

Terminal illness

Death of a client

Hardship

A nurse is caring for a client whose religious belief prohibits them fro receiving blood products. The client states, ''My adult children dont agree with my beliefs and want me to receive a transfusion.'' Which of the following responses should the nurse make?

- ''Your children opinions do not matter.''
- ''You should receive blood products if it will save your life.''
- ''You have the right to choose what treatments are best for you.''
- ''Your health care provider will make the final choice on treatments that are in your best interest.''

''You have the right to choose what treatments are best for you.''

The client's beliefs and preferences are most important, and the nurse should respect these and advocate for the client, regardless of the outcome.

A nurse is caring for a client who has a prescription for opioid analgesia. The client tells the nurse, '' I dont want to take that medication because it makes me sleepy.'' Which of the following responses should the nurse make?

- ''You need to take the medication so that you will not be in pain.''
- ''This medication does not affect your reasoning ability.''
- ''Controlling pain is more important right now than your mental state.''
- ''I will speak to your provider to see if there is a different medication to treat your pain.''

''I will speak to your provider to see if there is a different medication to treat your pain.''

The nurse is advocating for the client by acknowledging the client's wishes and providing a possible solution.

A nurse is providing information to a client who is from the Baby Boomer generation about a newly prescribed medication. Using the information about generational preferences, which of the following methods of teaching should the nurse use?

- Send a text message
- Talk with the client in person
- Provide a link to a teaching video or animation
- A formal face to face meeting with written notes

Talk with the client in person

Most clients from the Baby Boomer generation prefer in-person interactions in which the nurse is engaged and attentive.

A nurse is caring for a client who tells the nurse, ''Something is Wong. I feel like god is so far away from me and I dont know what to do.'' Which of the following is the client experiencing?

- Medical futility
- Spiritual distress
- Palliative care
- Caritas process

Spiritual distress

A nurse is caring for a client who states the health care provider recommends treatment to provide comfort because a cure is not possible. To which of the following concepts is the provider referring?

- Palliative care
- Medically futile care
- Potentially inappropriate treatment
- Quality of life

Palliative care

Palliative care involves providing treatments that offer pain relief or enhance the quality of life, but do not provide a cure.

A nurse is assisting with developing a quality improvement (QI) plan to reduce the incidence of medication errors in an acute care unit. The nurse should recognize that which of the following actions is included in the identifying steps of QI process?

- Developing a plan to implement change
- Evaluating the results of the change
- Recognizing a need for change
- Implementing the plan of change

Recognizing a need for change

Recognizing a problem and a need for change is included in the identifying step of the QI process.

A nurse is assistting on a quality improvement committee to decrease the number of client falls occurring at night, After identifying the problem, which of the following is the next step the nurse should take?

- Implement the practice change
- Evaluate the results of the change
- Complete a literature review
- Communicate the outcomes with others

Complete a literature review

Evidence-based practice indicates the next step the nurse should take is to complete a literature review using credible sources of evidence.

A nurse is using evidence based practice (EBP) to address the incident of catheter-associated infections on a surgical unit. According to EBP, which of the following actions should the nurse take first?

- Identify a clinical problem
- Collect best evidence relevant to the question
- Evaluate studies to determine validity
- Share the findings with others

Identify a clinical problem

According to EBP, the first action the nurse should take is to identify a clinical problem.

A nurse is caring for a client who has suction equipment in their room. The client asks the nurse, ''Why do you check my suction equipment every day even though I am not using it?'' Which of the following statements should the nurse make?

- ''It is part of an outcome audit that is being performed.''
- ''It is part of quality assurance plan of the unit.''
- It is part of a plan developed by your case manager.''
- ''It is part of a quality improvement program.''

''It is part of quality assurance plan of the unit.''

Quality assurance is a system that focuses on a problem-driven approach to improve client outcomes and promote a safe physical environment. Routine maintenance checks are part of the quality assurance process and are performed to ensure equipment is in proper working order.

A nurse is assisting a quality improvement team that is using the Plan-Do-Study-Act (PDSA) model to address an increase in pressure injuries on a medical unit. Which of the following actions should the nurse identify as an example of the ''Do'' step of the PDSA model?

- Reviewing data collected on clients who received the new protocol
- Developing a plan to initiate a change in client care
- Implementing a new evidence based practice protocol
- Accepting the new protocol in the units policy and procedure guidelines

Implementing a new evidence based practice protocol

The "Do" step of the PDSA model includes implementing the plan.

A nurse is explaining National Patient Safety Goals (NPSGs) to a newly licensed nurse. The nurse should include that which of the following is a goal addressed in the NPSGs?

- Improving staff communication
- Improving staff retention
- Increasing client satisfaction
- Increasing client involvement in their plan of care

Improving staff communication

NPSGs were established to improve quality of care by addressing certain client safety concerns. These safety concerns include infection prevention, reduced medication and surgical errors, improved client identification, and increased communication among staff members.

A nurse is assisting with teaching a class about incident reports. The nurse should include that which of the following situations requires an incident report?

- A client vomits after receiving oral mediation
- A client refuses to take a medication
- A nurse administers an antibiotic to a client 25 min after the scheduled time
- A nurse administers the wrong medication to a client

A nurse administers the wrong medication to a client

Administering the wrong medication to a client requires an incident report. The nurse should monitor the client for adverse effects and report the incident to the charge nurse or the provider.

A nurse is assisting with teaching a class about sentinel events. The nurse should include that which of the following situation is a sentinel event?

- A nurse infused an incompatible blood product to a client
- A client fell getting out of bed
- A client who is confused walks out of the nursing unit
- A nurse receives a needle stick injury from a contaminated needled

A nurse infused an incompatible blood product to a client

A sentinel event is a serious, reportable event that results in death, permanent harm, or severe injury to a client. Examples of sentinel events include wrong site surgery, client suicide while in a health care facility, and infusion of an incompatible blood product.

A nurse is reviewing a health care facilitys policy that states to use gauze dressing over IV insertion sites. After completing a literature reverie, the nurse discovers that evidence based practice (EBP) indicates to use a transparent dressing over IV sites. Which of the following actions should the nurse take next?

- Recommend changing the procedure to the policy and procedure committee
- Evaluate the results of the change in procedure
- Implement the change into clinical pracice
- Communicate the outcomes of the procedure change with others

Recommend changing the procedure to the policy and procedure committee

EBP indicates the next step the nurse should take is to recommend changing the procedure to the policy and procedure committee.

A nurse is assisting with teaching a newly licensed nurse about the hospital consumer assessment of healthcare providers and systems (HCAHPS) tool. Which of the following information should the nurse include?

- The HCAHPS tool is provided to client upon admission to a facility
- The HCAHPS tool is completed during an in person interview
- The HCAHPS tool is issued to measure client satisfaction about health care service.
- The HCAHPS tools results are not shared with the public

The HCAHPS tool is issued to measure client satisfaction about health care service.

The HCAHPS tool is issued to measure client satisfaction about health care service. The information is publicly reported and ensures the accountability and transparency of the facilities that participate.

A nurse is assisting with teaching a class about types of research studies. the nurse should include that which of the following is an example of a randomized controlled trial (RCT)?

- A study examining environmental factors that lead to obesity
- A study comparing a group of people who have diabetes mellitus with a group of people who do not have diabetes mellitus
- A study examining the cause of falls in a long term healthcare facility
- A study arbitrarily assigning people who smoke into with an experimental group or a control group to determine the effects of new therapy to reduce smoking

A study arbitrarily assigning people who smoke into with an experimental group or a control group to determine the effects of new therapy to reduce smoking

The nurse should include that a study randomly assigning people who smoke into either an experimental group or a control group to determine the effects of a new therapy to reduce smoking is an example of a RCT.

A nurse is a member of a committee that is using evidence based practice (EBP) to decrease the incidence of central line infections. The nurse should identify that which of the following interventions is part of the implementation step of EBP?

- Recognizing a high incidence of central line infections
- Evaluating whether the practice changes decreased the infection rate
- Researching best practices to reduce the rate of central line infections
- Incorporating the new practice into client care

Incorporating the new practice into client care

Incorporating the new practice into client care is part of the implementing step of EBP.

A nurse is discussing quality measurement with a newly licensed nurse. The nurse should include that medication reconciliation is an aspect of which the following parts of quality measurement?

- Bechmark
- Structure
- Outcome
- Process

Process

Medication reconciliation is included in the process category of quality measurement. The process category includes activities of delivering care, such as administering medications, implementing fall precautions, and performing a medication reconciliation.

A nurse is assisting with teaching a class about quality core measures. Which of the following information should the nurse include?

- A cost effective analysis is used to identify quality core measures
- Quality core measures are standard of care for treatment
- Client satisfaction is an example of quietly core measure
- Quality core measures are filled out by clients to evaluate healthcare facility services

Quality core measures are standard of care for treatment

Quality core measures are standards of care required for health care facilities to ensure they are providing best practices of care.

A nurse is assisting with using the Plan-Do-Study-Act (PDSA) model to decrease client falls in a long term care facility. The nurse should identify that developing guidelines to decrease falls in included in which of the following steps of the PDSA model?

- Do
- Plan
- Study
- Act

Plan

Developing guidelines to decrease falls is part of the "Plan" step of the PDSA model. In the planning step, the need for a change is identified, and plans are developed to initiate the change.

A nurse is orienting a newly licensed nurse to the unit Which of the following statements by the newly licensed nurse indicates an understanding of the importance of documentation of client education?

- ''Client documentation can decrease hospital reimbursement.''
- ''Client documentation can decrease the need to re-evaluate the clients educational needs.''
- ''Client documentation can increase staffing and services.''
- ''Client documentation can increase liability.''

''Client documentation can increase staffing and services.''

Accurate documentation ensures the health care facility is reimbursed for services, which allows the facility to maintain or increase staffing and services.

A nurse is reviewing a clients plan of care. ''The client will ambulate 20 feet using a walk'' is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify as missing from the outcome?

- Specific
- Timed
- Measurable
- Achievable

Timed

Timed is not demonstrated in the written outcome because there is no time frame in which to measure the outcome.

A nurse is teaching a group of newly licensed nurses about client education. Which of the following information should the nurse include in the teaching?

- Documentation of client eduction is not required for Joint Commission accreditation
- Client education does not change a clients values
- Client eduction does not influence the clients pain level
- Client education can improve self care at home

Client education can improve self care at home

Client education does improve self-care at home and decreases visits to the emergency department or urgent care facilities.

A nurse is discussing the nurses role in client education with a newly licensed nurse. Which of the following statement sibyl the newly licensed nurse indicates an understanding of a nurses role?

- ''Nurses make up the greatest percentage of members on a healthcare team.''
- ''Providers Mae up the greater percentage of members on a health care team.''
- ''Physician assistants have the greatest percentage of members on a health care team.''
- ''Physical therapists have the greatest percentage of members on a health care team.''

''Nurses make up the greatest percentage of members on a healthcare team.''

Nurses make up more than 70% of the health care team. Therefore, they play a significant role in client education. Client education has played a historically significant role in nursing. Florence Nightingale certified this as a nurse's function.

A nurse is panning a smoking cessation program for a client. Which of the following actions is a component of SMART outcome goals?

- Providing a reward for accomplishing the outcome
- Providing motivation to accomplish the outcome
- Providing a time frame to accomplish the outcome
- Providing demonstration on hoe to complete the outcome

Providing a time frame to accomplish the outcome

Timing the outcome provides a different view of the outcome in addition to being realistic.

A nurse is admitting a client for surgery. Which of the following questions should the nurse ask to determine the clients health literacy level and learning needs?

- ''Who will be your support person while your in the hospital?''
- ''Can you tell me what surgical procedure you are scheduled for?''
- '' How do you plan to care for yourself when you go home after surgery?''
- ''How comfortable are you with filling out medical forms by yourself?''

''How comfortable are you with filling out medical forms by yourself?''

Research has found that asking this question quickly predicts a client's health literacy. This information allows the nurse to better identify the client's learning needs and implement individualized teaching strategies that can best meet those needs.

A nurse is reviewing the goals of client education with a newly licensed nurse. Which of the following information should the nurse include?

- Improvement of health
- Provide knowledge about an illness or injury
- Relevance
- Health promotion
- Motivation

Improvement of health

Provide knowledge about an illness or injury

Health promotion

A nurse is participating in a question and answer session with a client. Which of the following domains of learning uses this type of client education?

- Cognitive domain
- Affective domain
- Psychomotor domain
- Adaptation domain

Cognitive domain

A nurse is evaluating a clients plan or care. The desired outcome of having the client sit on the side of try bed by the end of shift was not met. Which of the following actions should the nurse take?

- Determine if different nursing interventions are required
- Formulate a new analysis
- Notify the health care provider
- Notify physical therapy to assist getting the client out of bed to meet goals

Determine if different nursing interventions are required

The first step the nurse should take when an outcome is not achieved is to determine if different nursing interventions are required, whether the care plan was realistically achievable for the client, or if the care plan was not carried out properly. If possible, the nurse should always follow the steps of the nursing process when evaluating the care plan.

A nurse is planning an in service for staff nurses about psychomotor client teaching strategies. Which of the following activities requires the use of gross motor skills? (SATA)

- A client walking with crutches
- A client using a manual wheelchair
- Administering an intradermal injection to a client
- Opening a clients medication bottle
- Applying adhesive bandage to a clients finger

A client walking with crutches

A client using a manual wheelchair

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

- Ask the clients family member to translate
- Request a medical interpreter to be present
- Ask another nurse on the unit to translate
- Provide the client with only written materials

Request a medical interpreter to be present

Nurses should use certified medical interpreters when providing education to clients who speak a different language than they do.

A nurse is preparing a low stimulus environment for an education session on smoking cessation. Which of the following should the nurse implement?

- Set the thermostat to a comfortable temperature
- Dim the lights in the room
- Leave the door open during the educational session
- Play relaxing music

Set the thermostat to a comfortable temperature

Learning is best achieved in a private, low-stimulus environment. A low-stimulus environment provides good ventilation, adequate lighting, a comfortable temperature, and a decreased noise level.

A nurse is providing teaching to a client who has a recent diagnosis of pancreatic cancer. The nurses using strategies in the affective domain of learning. Which of the following client statements is part of the affective domain?

- ''I have been crying a lot since I learned about my diagnosis. Im worried about everything.''
- ''I am learning how to take my blood pressure so I can check it at home everyday.''
- ''I understand I may lose wright because I may not feel like eating much.''
- ''I will take my pain medication on a schedule to prevent my pain from becoming severe.''

''I have been crying a lot since I learned about my diagnosis. Im worried about everything.''

The affective domain of learning involves the client's feelings regarding values, attitudes, and beliefs. This statement by the client reflects the affective domain of learning.

A nurse is preparing to educate a client about the proper procedure for a dressing change. Which of the following indicates an understanding of Knowles fundamental principles of client readiness?

- The client states, 'I will do it myself.'
- The client has been awake all night
- The client is engaged and alert
- The client used to help change their partners dressing

The client is engaged and alert

For education to be effective, the client must show readiness to learn, including the ability to engage.

A nurse is reviewing information about client education with a newly licensed nurse. Which of the following information should 4th ensures include as the focus of client education?

- Empowering clients to be accountable for self care
- Providing the client with disease orientated education
- Providing education only to the cline to protect confidentiality
- Encouraging clients to let go of previous experiences

Empowering clients to be accountable for self care

One of the main purposes of client education is to empower clients to be comfortable with and accountable for their own self-care.

A nurse is preparing for a teaching session with a client who has pernicious anemia. Which of the following should the nurse identify as part of the implementation process?

- Determine the clients health literacy
- Develop a teaching plan that meets the clients needs
- Use demonstration to tech the client about Vitamin B12 injections
- Determine if the client has met the goals

Use demonstration to tech the client about Vitamin B12 injections

This is an example of the implementation step in the teaching process.

A nurse is providing teaching about performing blood glucose checks to a client who has a new diagnosis of diabetes mellitus. Which of the following actions indicates the nurse is using the affective domain of learning?

- Ask the client how they feel about checking their blood glucose levels
- Ask the client to demonstrate how to check their blood glucose level
- Ask the client to verbalize the steps of checking their blood glucose level
- Ask the client if they understand the importance of monitoring their blood glucose level

Ask the client how they feel about checking their blood glucose levels

During educational instruction, the nurse might provide information that affects the client's feelings. The client will need to evaluate their values, attitudes, and beliefs to process the educational material and apply it to their situation.

A nurse is preparing for a teaching season with a client. Which of the following actions should the nurse take to provide the client with unbiased care? (SATA)

- Avoid assumptions about the client
- Compare the client to a former client
- Ask the coworkers to share their past experiences with similar clients
- Control personal thoughts about the client
- Collaborate with another nurse to develop teaching strategies

Avoid assumptions about the client

Control personal thoughts about the client

Collaborate with another nurse to develop teaching strategies

A nurse is providing teaching to a client who has a new prescription for eye drops. Which of the following teaching strategies is an example of using the psychomotor domain of learning?

- Discuss with the client how to use the eye drops
- Encourage the client to ask questions about the medication
- Provide the client with a handout that explains how to use the medication
- Ask the client to teach back about how to use the medication

Ask the client to teach back about how to use the medication

A nurse is planning a 30-min group education class. Which of the following actions should the nurse plan to take to dress carious learning styles related to the domains of learning?

- Give demonstrations only
- Provide games, discussion, and question and answer
- Repeat demonstrations at the completion of class and lecture
- Allow time for role play and demonstration

Provide games, discussion, and question and answer

Games address the psychomotor learning domain, discussion addresses the affective learning domain, and question-and-answer addresses the cognitive learning domain.

A nurse is teaching a client about how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach back method of learning?

- ''Show me again how to position the blood pressure cuff on my arm.''
- ''I have an electronic blood pressure machine at home that I will use.''
- ''I believe I can take my blood pressure successfully after talking through the steps.''
- ''Let me show you how I will take my blood pressure at home each day.''

''Let me show you how I will take my blood pressure at home each day.''

The success of teach-back is evaluated by asking the client to repeat the educational information back to the nurse in their own words or allowing the client to demonstrate a skill that they have been taught. This statement by the client indicates understanding and is an example of the teach-back method of learning.

A nurse is planning a teaching session for a client. Place the steps of the teaching process in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

- Planning
- Analysis
- Evolution
- Assessment
- Implementing

1. Assessment
2. Analysis
3. Planning
4. Implementation
5. Evaluation

A nurse is caring for a client who has impaired cognition and has begun taking a new medication. Which of the following actions should the nurse take during client education?

- Expect the client to understand the information
- Direct the education to the caregivers as well as the client
- Provide written handouts only
- Speak quickly

Direct the education to the caregivers as well as the client

Impaired cognition can be temporarily related to emotions such as stress or from a physical or mental disability. The nurse might not be able to recognize impaired cognition until after the evaluation process. A client might benefit from caregiver involvement and frequent evaluations.

A nurse is using a question and answer session to teach a client about a diabetic diet. Which of the following outcomes is an example of cognitive learning?

- The client will be able to prepare a diabetic meal
- The client understands a diabetic meal plan
- The client accepts a diabetic meal plan
- The client states, ''I am never giving up soda and candy.''

The client understands a diabetic meal plan

A client who is thinking through information and comprehending it is engaging the cognitive domain of learning.

A nurse is assessing a clients health literacy prior to providing education. Which of the following actions should the nurse take? (SATA)

- Ask questions regarding the clients healthcare needs and concerns.
- Obtain a health history
- Assess the client education level
- Perform a physical assessment
- Use medical terminology when educating the client

Ask questions regarding the clients healthcare needs and concerns.

Obtain a health history

Assess the client education level

A nurse is assessing a postoperative client prior to a teaching session. The nurse notes that the client is grimacing and restless. Which of the following barriers to learning is the client exhibiting?

- Psychomotor deficit
- Depression
- Physical discomfort
- Lack of motivation

Physical discomfort

Physical discomfort is a barrier to learning and is exhibited by nonverbal cues such as grimacing and restlessness. A client who is in pain is unable to focus on much else other than the pain, especially if it is severe. The nurse should implement interventions to alleviate the client's pain before teaching.

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

- The most common oral hygiene problem is gingivitis/
- The clients ability to obtain dental care in unaffected by their visual impairment
- The visually impaired client has better oral hygiene than those clients without visual impairment
- The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health

It is essential for the nurse to educate the client and caregivers regarding the need for routine dental visits to decrease the risk of developing oral health problems.

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?

- Changes in skin integrity decrease the risk of infection
- Urinary incontinence can cause a yeast infection
- Mild nap is contraindicated for cleaning the skin
- A pH balanced cleanser increases skin irritation

Urinary incontinence can cause a yeast infection because of excessive moisture.

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

- nails, made of pterygium, protect the fingers and toes
- The cuticle is a form of keratin that connects the skin and nail plate together
- The cuticle of the nail forms a barrier to prevent infections
- The nails consists of the layers of pterygium that protect against pathogens

The cuticle of the nail forms a barrier to prevent infections

The cuticle of the nail connects the skin on the finger and nail plate, forming a barrier to prevent infections.

A nurse is teaching the importance of hand washing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting?

- ''It is important to wash your hands after removing gloves.''
- ''Effective hand washing can decrease hospital infection rate.''
- ''Infections in health care staff are not considered health care associated infections.''
- ''Healthcare associated infections are a rare event in health care delivery.''

''Effective hand washing can decrease hospital infection rate.''

Evidence has shown effective handwashing can decrease hospital infection rates.

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?

- ''The skin contains Langerhans cells that kill pathogens.''
- ''The skin is the second line of defense against micro-organisms.''
- ''The dermis is the outermost layer of the skin.''

''The skin contains Langerhans cells that kill pathogens.''

Langerhans cells within the skin sense the presence of disease-causing pathogens and destroy them, decreasing the risk of developing infection in the body.

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?

- Health promotion programs emphasize behavior changes in relation to prevention of illness
- Health promotion programs encourage decreased use of health services.
- Health promotion programs restrict the clients control over their general health
- Health promotion programs discourage community involvements

Health promotion programs emphasize behavior changes in relation to prevention of illness

Health promotion programs emphasize encouraging the client to take control of improving their overall health.

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

- ''The mucous membranes secrete a thin, salty liquid that traps pathogens and particles.''
- ''The mucous membranes of the auditory tube contain cilia that move particles toward the front of the nose.''
- ''The mucous membranes in the nose that contain cilia that traps particles preventing the from invading the body.''

''The mucous membranes in the nose that contain cilia that traps particles preventing the from invading the body.''

Cilia in the nose trap particles as a person inhales, preventing particles from invading the body.

A nurse is caring for an older adult client whose caregiver reports that tithe client is resistant to bathing at home. Which of the following statements should the nurse make?

- ''That is unusual. As clients age, they are typically more receptive to bathing.''
- ''It is fine if the client does not bathe regularly at home.''
- ''Give the client choices regarding their bathing preferences to encourage them to bathe.''
- ''Provide the client with the reasons why they need to bathe.''

''Give the client choices regarding their bathing preferences to encourage them to bathe.''

Giving the client choices about bathing preferences may persuade them to bathe or shower.

A nurse is caring for a client who has bariatric care needs and has a rash between skin folds. Which of the following actions should the nurse take?

- Assist the client as needed to ensure proper hygiene is performed.
- Aggressively rub the skin folds dry to manage moisture.
- Use a lye soap bar to cleanse the skin folds and the rash area.
- Apply moist to the skin folds and rash area

Assist the client as needed to ensure proper hygiene is performed.

The nurse should assist the client as needed because it might be difficult for the client to reach some areas on their body.

A nurse is performing foot care for a client. Which of the following actions should the nurse take?

- Soak the feet prior to washing the feet
- Use hot water when performing foot care
- Use a towel too completely dry between the toes
- File the nail edges straight across with a file

Use a towel too completely dry between the toes

It is important to completely dry between the toes because infections are more likely to develop in moist areas.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (SATA)

- The nurses hands become visually soiled
- The nurse removes the meal tray of a client who has infectious diarrhea
- The nurse moves the cell phone of a client who has pneumococcal pneumonia from the bedside table.
- The nurse empties the urinal of a client who has Clostridium difficile.
- The nurse is preparing to insert an intravenous catheter.

The nurses hands become visually soiled

The nurse removes the meal tray of a client who has infectious diarrhea

The nurse empties the urinal of a client who has Clostridium difficile.

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take?

- Ensure the nurse is caring for the client is of the same sex
- Leave the water running while the client takes a bath
- Allow the client time for prayer immediately following bath time
- Discuss with a client their. individual perspectives on the health and illness.

Discuss with a client their. individual perspectives on the health and illness.

It is important for the nurse to discuss religious preferences with the client because there are various religions with differing perspectives.

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?

- Enamel protects the teeth from pathogens.
- Enamel is a substance that cannot be dissolved.
- Enamel is a soft material that protects the teeth
- Enamel covers the pulp

Enamel protects the teeth from pathogens.

Enamel protects the teeth from pathogens by providing a coating that covers the teeth.

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

- Trim the nails to a length that reaches beyond the edge of the finger
- Performing hand hygiene once nail hygiene is complete
- Avoid the use of wooden orange sticks
- Trim the nails straight across

Trim the nails straight across

Nails should be trimmed straight across and then a file can be used to smooth any rough nail edges.

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

- Bathing the client completely in bed preserves the clients dignity
- Washing the client in bed is less effective than taking a shower
- A complete bed bath should be performed using a basin, soap, and water
- Perform this type of bathe

Washing the client in bed is less effective than taking a shower

Washing a client in bed is less effective than taking a shower and should only be used when there is no other option available.

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (SATA)

- A fluoride mouthwash should be used to promote oral health
- The teeth should be brushed twice daily 2 min
- Teeth should be flossed every other day
- Use a soft bristled toothbrush for brushing the teeth

A fluoride mouthwash should be used to promote oral health

The teeth should be brushed twice daily 2 min

Use a soft bristled toothbrush for brushing the teeth

A nurse is caring for a client who has right sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?

- The nurse should perform personal hygiene tasks for client.
- The client has minor loss of strength on the right rise of he body.
- The nurse should have the client remove clothing from there unaffected side first
- Oral care is much easier of the client to perform than bathing

The nurse should have the client remove clothing from there unaffected side first

When assisting the client with dressing, the unaffected arm is used first to place clothing on the affected side. When undressing, the clothing is removed from the unaffected side first, then the affected side.

A nurse is reviewing the anatomy of the skin with a newly listened nurse. Which of the following information should the nurse include as a characteristic of the periderms?

- The epidermis acts as a cushion against physical trauma.
- The epidermis separates the dermis from th underlying organs
- The epidermis consists of squamous epithelial cells
- The epidermis contains blood vessels and blood

The epidermis consists of squamous epithelial cells

The epidermis is made of squamous epithelial cells that form four layers, providing strength to the skin.

A nurse is reviewing hand washing skills with a newly licensed nurse. In which order should;d the nurse pan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

- Apply the amount of soap recommended by the manufacture
- Wet hands with warm water
- Rub hands together vigorously for at least 15 seconds
- use a towel to run of the faucet
- use a disposable towel to dry
- Rinse hands with water

Wet hands with warm water

Apply the amount of soap recommended by the manufacture

Rub hands together vigorously for at least 15 seconds

Rinse hands with water

Use a disposable towel to dry

Use a towel to run of the faucet

A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?

- ''A standard toothbrush is more effective than a battery operated toothbrush in decreasing plaque.''

- ''Clean the lounge with the toothbrush or lounge scraper during oral hygiene.''

- ''Flood the teeth at least three times a day.''

- ''Have the client use the mouthwash after brushing their teeth.''

''Clean the lounge with the toothbrush or lounge scraper during oral hygiene.''

The tongue should be cleaned during oral hygiene to remove bacteria that can be found on the tongue.

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

- Pivot disc
- Mechanical lift
- Sit to stand lift
- Gait belt

Mechanical lift

The nurse should use a mechanical lift, along with assistance from two or more health care staff, to transfer a client who is unable to assist. The use of a mechanical lift decreases the risk of injury to both the staff and the client.

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

- Twisting the torso when transferring the client
- Bending at the waist when transferring the client
- Placing the bed in the high position before transferring the client
- Looking at the client face to face when transferring the client

Looking at the client face to face when transferring the client

The nurse should look at the client face-to-face when transferring. This prevents twisting or turning of the torso, which can cause back injuries.

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

- Cartilage is always remodeling and changing
- Tendons connect muscle to bone
- Ligaments are flexible connective tissue that coat bony areas
- Synovial joints attach to the skeleton to maintain posture

Tendons connect muscle to bone

Tendons and ligaments are both made of fibrous connective tissue. Tendons attach muscle to bone while ligaments attach bones to other bones.

A nurse is preparing to lift a heavy object off the floor. in which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps).

- Look straight ahead with shoulders raised up
- Keep abdominal muscles contracted and the lower back straight
- Stand as close to the object as possible
- Bend hips slightly and squat
- Push up from the knees when lifting the objects

Stand as close to the object as possible

Keep abdominal muscles contracted and the lower back straight

Look straight ahead with shoulders raised up is the third step.

Bend hips slightly and squat is the fourth step.

Push up from the knees when lifting the object is the fifth step.

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

- Kyphosis is hen the upper back extends posteriorly to the lower back
- Kyphosis is an inward cube of he lower back
- Kyphosis is a sideways curvature of the spine
- Kyphosis is a rounded upper back with the pelvis tilted forward

Kyphosis is a rounded upper back with the pelvis tilted forward

Kyphosis is when the upper back is abnormally rounded with the pelvis tilted forward.

A nurse is caring for a client who has pneumonia, In which of the following positions should the nurse place the client to promote postural drainage?

- Lateral
- Supine
- Prone
- Fowlers

Prone

The nurse should place the client who has pneumonia in the prone position to promote postural drainage. In this position, the client lies flat on their abdomen with their head turned to the side.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

- The hand grips of the crutches are at the level of the clients umbilicus
- The client elbows are bent 45 degrees when holding the crutches
- The client places their weight on their axilla when using the crutches
- The client has the crutches resting 5cm (2in) below their axilla

The client has the crutches resting 5cm (2in) below their axilla

The nurse should identify that the client is using the crutches properly when they rest the crutches 5 cm (2 in) below their axilla.

A nurse is teaching an in service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

- The use of ergonomics improves blood circulation in the body
- The use of ergonomics eliminates costs related to workers compensation
- The use ergonomics increase job satisfaction
- The use of ergonomics maintains the body balance and lower center of gravity

The use ergonomics increase job satisfaction

The use of ergonomics increases job satisfaction along with productivity of staff members. When staff members can work safely and effectively, they can perform at a higher level.

A nurse is performing a focused assessment on an older adult clients mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age related change to their muscoskeletal system?

- Increased curvature of the thoracic spine
- Reduced depth perception
- Narrower stance when standing
- Quick steps when ambulating

Increased curvature of the thoracic spine

The nurse should identify that an increased curvature of the thoracic spine, along with protrusion of the neck, indicates an age-related change to the client's musculoskeletal system. This occurs due to bone loss and degeneration of vertebral discs. This can cause the client to lean forward when standing and have an unsteady gait when walking.