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ATI - Fundamentals of Nursing Proctored Test Bank With 600 plus Questions and Answers

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ATI - Fundamentals of Nursing Proctored Test Bank With 600 plus Questions and Answers- -incorrect: The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. Thistype ofdressing is ... applied to facilitate debridement and to soften eschar. A nurse on a medical-surgical unit observes smoke billowing from a client’s room. Whichofthe following actions should the nurse take first? a. Close the door to the client’s room -incorrect: The nurse should close the doors and windows in the immediate vicinity to helpcontain the fire; however, this is not the first action the nurse should take. b. Evacuate the client from the room -The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is rescuing orremoving the client from immediate danger. The second action is activation of the fire alarm system. The third action is confining the fire by closing doors and windows. The final action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to extinguish a fire could compromise the safety of clients or staff members, the nurse should awaitthe arrival of emergency firepersonnel. c. Sound the fire alarm -incorrect: The nurse should sound the fire alarm to summon fire professionals to put out the fireandensure safety in the facility; however, this is not the first action the nurse should take. d. Activate the fire extinguisher -incorrect: The nurse should attempt to extinguish the fire safely if possible; however, this is notthefirst action the nurse should take. A. nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include inthe teaching? a. Exhale slowly to reach the goal volume -incorrect: The nurse should instruct the client to inhale slowly to reach the goal volume and todecrease the collapse of alveoli in the client’s lungs. b. Hold the breath for 5 sec after goal volume is reached -The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasisand pneumonia. c. Continue to breathe deeplybetween each cycle -incorrect: The nurse should instruct the client to breathe normally for short periods of timebetween each cycle ofbreaths to reduce hyperventilation and fatigue. d. Limit the repeat pattern ofbreathing to 5breaths -incorrect: The nurse should instruct the client to repeat the patterns for 10 to 20 breathes everyhourwhile awake to prevent atelectasis and pneumonia. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of thefollowing abdominal assessments should the nurse expect? a. Frequentbowel sounds with flatus b. Absent bowel sounds with distention -Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and theabdomen is distended. c. Hyperactive bowel sounds with diarrhea d. Normalbowel sounds with increased peristalsis -incorrect A/C/D: With paralytic ileus, bowel sounds are absent, the abdomen is distended andthereis no flatus or stool. A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften thefeces? a. Carminative -incorrect: The nurse should administer a carminative enema to assist a client to expel flatus. b. Hypertonic -incorrect: The nurse should administer a hypertonic fluid solution to cleanse the client’s bowels(ex: inpreparation for surgery). c. Oil retention -The nurse should administer an oil retention enema prior to the removal of a fecal impaction tosoftenthe stool. This makes the procedure less painful for the client. d. Sodium polystyrene sulfate -incorrect: The nurse should administer a sodium polystyrene sulfate enema to a client who has ahighpotassium level. A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? a. „I‟ll wear nonsterile gloves.” -Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client’s hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes. b. “I’ll use adhesive remover each time.” -incorrect: The client should use adhesive remover only if tape removal or residual adhesivecreatessignificant problems on especially sensitive skin. c. “I’ll take mypain pill after I change the dressing.” -incorrect: If the client expects the dressing removal to hurt, the client should take an analgesiclongenoughbefore the dressing change for the medication to take effect. d. “I’ll fold the dressing with the soiled surface facing outward.” -incorrect: The client should remove the dressing by folding the soiled surfaces inward to preventthetransfer of microorganisms to the client’s hands and other surfaces. [Show More]

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