ATI Fundamentals Practice 2023 A

A nurse is caring for a client who is postoperative following abdominal surgery.

Exhibit 1

Nurses' Notes 1100:Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach.1115:Provider prescriptions reviewed.1200:Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted.

Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again.

**Urinary output**

**Reported pain level**

**Vital signs**

Neurological assessment is incorrect. The client is oriented to person, place, and time. They are able to move all extremities and have no obvious indication of neurological compromise.

Incisional drainage is incorrect. While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.

Urinary output is correct. A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should assess the catheter's placement and potential for blockage due to their reduced urine output. This finding should be reported to the provider.

Reported pain level is correct. The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increasing. This finding should be reported to the provider.

Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.

Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

"Maintain a consistent time to wake up each day."

Explanation: The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

Wear a gown when caring for the client.

Explanation: The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?"

Explanation: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place.

Explanation: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is caring for a client who has a sodium level of 125 mEq/L (136 to 145 mEq/L). Which of the following findings should the nurse expect?

Abdominal cramping

Explanation: This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions

Explanation: Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

"I want you to tell me about measures available to keep me comfortable."

Explanation: This statement would indicate that the client has accepted that their diagnosis is terminal and is focusing on the goals of palliative care, which are comfort and manifestation control.

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

Correct:

**Place the client in a room with negative-pressure airflow**

Explanation: The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions.

**Wear gloves when assisting the client with oral care**

Explanation: The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth.

**Use antimicrobial sanitizer for hand hygiene**

Explanation: The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

Incorrect:

- Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room.

- Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager.

Explanation: The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

Explanation: The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system."

Explanation: Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

Correct:

**Assist the client with a partial bed bath**

Explanation: Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function.

**Measure the client's BP after the nurse administers an antihypertensive medication**

Explanation: Measuring a client's BP poses minimal risk to the client and is within the AP's range of function.

**Use a communication board to ask what the client wants for lunch**

Explanation: Using a communication board poses minimal risk to the client and is within the AP's range of function.

Incorrect:

- Test the client's swallowing ability by providing thickened liquids is incorrect.

Explanation: Assessing the client's swallowing ability places the client at risk for aspiration and is not within the AP's range of function. Nurses perform tasks that require assessment.

- Irrigate the client's indwelling urinary catheter is incorrect.

Explanation: Irrigating the client's indwelling urinary catheter is an invasive procedure and is not within the AP's range of function.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside their room if there is construction in the area.

Explanation: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. The nurse should place the client in a private room that provides positive-pressure airflow. The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment. A protective environment requires at least 12 air exchanges per hour.

A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus.

Explanation: An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider?

Potassium 5.8 mEq/L (3.5 to 5 mEq/L)

Explanation: When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

Explanation: For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion.

Explanation: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

Explanation: Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins

Explanation: Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

Explanation: Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

Explanation: Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

Explanation: With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid

Explanation: Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed.

Explanation: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client.

Explanation: According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1: Obtain the pronouncement of death from the provider.

2: Remove tubes and indwelling lines.

3: Wash the client's body.

4: Ask the client's family members if they would like to view the body.

5: Place a name tag on the body.

Explanation: The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding their daily routine.

Explanation: The nurse should allow the adolescent to make decisions regarding their daily routine in order to give them a sense of control.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid heart rate

Explanation: Tachycardia is manifestation of fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

"Client found lying on floor."

Explanation: The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.

A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position.

Explanation: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion 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.)

107 mL/hr

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher.

Explanation: The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

Explanation: The client's statement indicates a readiness to learn because they are verbalizing the best time for them to learn.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine.

Explanation: A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while the client is asleep.

Explanation: The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30°.

Explanation: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

Explanation: According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old."

Explanation: The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

Explanation: This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

"Would you like it if we discussed the transfer with your family member?"

Explanation: This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

Explanation: The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?

Assist the client to an upright position.

Explanation: According to evidence-based practice the nurse should assist the client to an upright position. This assists with chest expansion and increases the effectiveness of the existing supplemental oxygen. The nurse should elevate the head of the client's bed to the semi-Fowler's or high-Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

Explanation: The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the client's plate.

Explanation: Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload

Explanation: The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions.

Explanation: The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

"It might help me to listen to music while I'm lying in bed."

Explanation: Listening to music is an effective nonpharmacological intervention for the management of mild pain.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet

Explanation: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

Explanation: The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

Explanation: Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing.

Explanation: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.

A nurse is caring for a client in a medical-surgical unit.

Exhibit 1 Nurses' Notes0800: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.0830:Reassessed client pain level; client states pain is now a 3 on a scale of 0 to 10.0930:Assisted client to chair at bedside. Client states they felt "lightheaded" when standing up. Vital signs obtained.1000:Assisted client back to bed. Dressing dry and intact. Sequential compression devices reapplied.

**- Administer analgesic prior to planned activities.**

**- Assist the client to dangle their legs at the bedside prior to standing. **

**- Delegate the application of sequential compression devices to assistive personnel. **

Explanation: When generating solutions, the nurse should plan to administer analgesic prior to planned activities, assist the client to dangle their legs at the bedside prior to standing, and delegate the application of sequential compression devices to assistive personnel. Administering analgesia prior to activities can decrease pain and enable the client to perform their planned activities. Assisting the client to dangle their legs prior to standing can increase venous return and reduce orthostatic hypotension. The application of sequential compression devices can be delegated to assistive personnel after initial assessment by the nurse.

A nurse is caring for a client who has a new diagnosis of seizure disorder.

Exhibit 1 Nurses' Notes0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching.0900:On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help.

Exhibit 2 Medication Administration

Complete the following sentence by using the list of options.

The nurse should first address the client's **physical safety**

followed by the client's

**positioning.**

Explanation: Drop Down 1:Blood pressure is incorrect. The nurse should take the client's vital signs, but not while the seizure is in progress. Vital signs should be collected following the seizure.Physical safety is correct. The greatest risk to the client is injury from the seizure. Therefore, the first action the nurse should take is to ensure the client's physical safety by protecting the client's head. The nurse should cradle the client's head in their lap or place a pad underneath the head.Privacy is incorrect. The nurse should protect the client's privacy to the extent that they are able, but this is not the first action the nurse should take.Drop Down 2:PRN medication is incorrect. The nurse should stay with the client for the duration of the seizure to ensure their safety. The nurse should send another nurse to obtain the PRN medication.Positioning is correct. The nurse should attempt to turn the client on their side with their head tilted slightly forward. This position will protect the client's airway from the aspiration of any secretions that may occur. Therefore, this is the second action the nurse should take.Incontinence is incorrect. The nurse should address any incontinence that occurs during the seizure, but this should be done after the seizing is over and the client's safety is ensured.

A nurse in an emergency department is caring for a client. Exhibit 1 Physical Examination1200:Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids.

Exhibit 2 Vital Signs1200:Temperature 38.4° C (101.1° F)Heart rate 126/minRespiratory rate 28/minBP 92/54 mm HgOxygen saturation 93%

Exhibit 3 Nurses' Notes1900:Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left.1915:Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation.

Exhibit4 Medication Administration RecordDextrose 5% in 0.45% sodium chloride IV at 125 mL/hr

The nurse should first

**review medications that might cause confusion* followed by *using other methods to keep the client safe.**

Explanation: Drop Down 1:Review medications that might be causing confusion is correct. Using the nursing process, the first step the nurse should take is to assess for a cause of the client's confusion.Obtain a prescription from the provider for restraints is incorrect. The nurse should first assess for a cause of the client's confusion, followed by using alternative methods to protect the client from injury.Assess where the restraint will be placed on the client is incorrect. The nurse should first assess for a cause of the client's confusion, followed by using alternative methods to protect the client from injury.Drop Down 2:Padding bony prominences under the restraint is incorrect. If assessing for a cause and attempting alternative methods to keep the client safe is not effective, the nurse must first obtain a prescription from the provider before applying the restraint.Monitoring the client in restraints every 2 hr is incorrect. If assessing for a cause and attempting alternative methods to keep the client safe is not effective, the nurse must first obtain a prescription from the provider before applying the restraint.Using other methods to keep the client safe is correct. After assessing for the cause of the client's confusion, the nurse should attempt alternatives to the use of restraints, such as covering the client's IV lines or asking a family member to stay with the client. The use of restraints should be avoided if possible.

A nurse is admitting a client.

Exhibit 1 Nurses' Notes0930:Provider is admitting client for the management of presumptive bacterial pneumonia. Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. Client placed on droplet precautions.1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. Portable chest x-ray obtained.

Exhibit 2 Vital Signs1030:Blood pressure 110/68 mm HgHeart rate 110/minRespiratory rate 24/minTemperature 38.6° C (101.5° F)Oxygen saturation 91% on room air

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take?

Select all that apply.

**Place the client on droplet isolation precautions.**

**Apply oxygen at 2 L/min via nasal cannula.**

**Request a prescription for an antipyretic medication.**

**Remain 1 m (3 feet) from the client.**

Explanation: Place the client on droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions.Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client.Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 38.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever.Wear an N95 mask when providing care to the client is incorrect. The nurse should wear an N95 mask when providing care to clients who have an airborne infection and are in a negative air pressure room.Request a prescription for an antihypertensive medication is incorrect. The client's blood pressure is within the expected reference range. Therefore, a request for a prescription for an antihypertensive medication is not indicated.Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

A nurse in a provider's clinic is caring for a client who has diarrhea.

Exhibit 1 Vital SignsTemperature 36.2° C (97.2° F)Heart rate 116/minRespiratory rate 24/minBP 102/68 mm HgOxygen saturation 95%Weight 52.2 kg (115 lb)

Exhibit 2 Nurses' Notes1000:Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out."Client was seen 7 days ago for sinus infection and was prescribed amoxicillin.Weight at previous visit was 56.2 kg (124 lb).Denies bloody or black stools.1030:Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis.1100:Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution

**Eat probiotic foods, such as yogurt.**

**Avoid alcohol while experiencing diarrhea.**

**Avoid caffeine while experiencing diarrhea.**

**Follow a low-fiber diet.**

Explanation: Increase intake of high-calcium foods is incorrect. The nurse should instruct the client to increase intake of high-potassium foods.Eat probiotic foods, such as yogurt is correct. Probiotic foods, such as yogurt, contain live bacterial cultures, which can help to reduce diarrhea.Avoid alcohol while experiencing diarrhea is correct. Alcohol is a substance that stimulates gastrointestinal (GI) motility.Eat raw vegetables is incorrect. Raw vegetables contain fiber. The nurse should instruct the client to eat vegetables that are well-cooked and do not have skins or seeds.Eat three large meals a day is incorrect. The nurse should instruct the client to eat small meals throughout the day to manage diarrhea.Avoid caffeine while experiencing diarrhea is correct. Caffeine is a substance that stimulates GI motility.Drink hot liquids several times a day is incorrect. Hot liquids can stimulate peristalsis and should be avoided while the client is experiencing diarrhea.Drink carbonated beverages to replace lost fluids is incorrect. Items such as milk, fruit, and carbonated beverages can contain simple sugars that stimulate GI motility.Follow a low-fiber diet is correct. Foods that are high in fiber stimulate GI motility and should be avoided while the client is experiencing diarrhea.

A nurse in a provider's clinic is caring for a client who has heart failure.

Exhibit 1Exhibit 2Nurses' NotesFirst Clinic Visit:Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine.Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure.

"I am limiting my sodium intake to 2 grams daily."

"I am eating fewer potato chips and more fruit for snacks."

"I know to call my doctor if I gain 3 pounds or more in 2 days."

Explanation: "I have been weighing myself every other morning" is incorrect. The client should weigh in every day to monitor for fluid retention."I am trying to decrease my intake of foods with potassium" is incorrect. The client's furosemide dosage was increased, which can lead to increased elimination of potassium. Increasing potassium intake is a lifestyle modification that is important in controlling hypertension."I am limiting my sodium intake to 2 grams daily" is correct. Clients who have heart failure should maintain a sodium intake between 2 and 3 g daily."I am eating fewer potato chips and more fruit for snacks" is correct. Chips are a processed snack food that contains high levels of sodium. Additionally, fruits contain electrolytes and fiber, both of which are important to controlling blood pressure and lipid levels."I lie down and rest after meals" is incorrect. The client should be taught to lie down and rest before meals as eating requires energy and oxygen consumption. The client should also be instructed to eat small, frequent meals rather than large meals to help relieve shortness of breath and fatigue."I know to call my doctor if I gain 3 pounds or more in 2 days" is correct. The client should monitor weight on a daily basis and call the provider for a weight gain of 1.36 kg (3 lb) or more in 2 days to prevent an exacerbation of their heart failure.

A nurse in the emergency department (ED) is caring for a client.

Exhibit 1 Nurses' Notes1100:Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.1110:Provider at bedside; prescriptions received.1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.1200:Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities.

Exhibit 2 Medication Administration Record1115:Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting

Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again.

**Cachectic, with flaccid muscle tone.**

**Skin dry and scaly with bruises on extremities.**

**Pulse rate 118/min**

**Abdomen distended**

**BMI 17**

Explanation: Cachectic, with flaccid muscle tone is correct. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition.Skin dry and scaly with bruises on extremities is correct. The client's dry, scaly, and bruised skin can be an indication of malnutrition.Oriented x 3, able to move all extremities is incorrect. The client's neurological status is within expected parameters.Pulse rate 118/min is correct. The client's tachycardia can be an indication of malnutrition.Respiratory rate 18/min is incorrect. The client's respiratory rate is within the expected reference range.Abdomen distended is correct. The client's abdominal distention can be an indication of malnutrition.Temperature 39.2° C (102.6° F) is incorrect. An elevated temperature is not an indication of malnutrition.BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse is caring for a client who has a pressure injury.

Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain of pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain of pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed

Exhibit 2 Vital SignsDay 4:Temperature 38.3° C (101° F)Pulse rate 80/minRespiratory rate 20/min

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

**Temperature**

**WBC count**

**Prealbumin level**

**Pain Level**

**Odor of wound**

Explanation: Temperature is correct. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.WBC count is correct. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.Prealbumin level is correct. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider.Hemoglobin level is incorrect. The client's hemoglobin is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider.Blood pressure is incorrect. The client's blood pressure is above the expected reference range. However, it does not indicate a hypertensive crisis and is not associated with manifestations of the wound or infection. Therefore, the nurse does not need to report this finding to the provider.Pain level is correct. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider.Odor of wound is correct. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider