ATI RN Fundamentals Questions and Answers Already Passed

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A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? A. Admi... tting diagnosis B. Breath sounds C. Body Temperature D. Diagnostic test results B. Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30º. C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol. B. Tell the client to keep the head of the bed elevated at least 30º. 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 nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in a room with negative pressure airflow. B. Wear gloves when assisting the client with oral care. C. Limit each visitor to 2-hr increments. D. Wear a surgical mask when providing client care. E. Use antimicrobial sanitizer for hand hygiene. A, B, E A. Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. B. Wear gloves when assisting the client with oral care is correct. 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. C. 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. D. 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. E. Use antimicrobial sanitizer for hand hygiene is correct. 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. [Show More]

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