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Nr 324 Exam review ATI RN Fundamentals Proctored Focus Questions And Answers LATEST

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Nr 324 Exam review ATI RN Fundamentals Proctored Focus Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? A nurse on a med-surg unit has received change-of-shift ... report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? 1. Yes. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24hr postop to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump Rationale: The RN is responsible for the PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurse B. RN C. LPN D. AP A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for this, especially if the client is potentially unstable. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy By threatening the client, the AP is committing assault. An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality The nurse gave the med as a chemical restraint to keep the client from leaving the facility against medical advice. The client did not consent. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all. A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that her coworker's fatigue is not her problem to solve A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A nurse is preparing to preform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all. A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis, Q2-3 hours C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Limit suctioning to 2-3 attempts A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all. A. Apply the oxygen source loosely if the SPO2 decreases during the procedure B. Use surgical asepsis to remove & clean the inner cannula C. Clean the outer surfaces in a circular motion from the stoma site onward D. Replace the tracheostomy ties w/new ties E. Cut a slit in gauze squares to place beneath the tube holder. A provider is discharging a client with a prescription from home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all. A. Apply petroleum jelly around the inside of the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula often D. Report any nasal stuffiness, nausea, or fatigue E. Post "no smoking" signs in a prominent location A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been opened B. Verify the placement of the NG tube C. Confirm that the client doesn't have diarrhea D. Make sure the client is alert & oriented A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest xray D. Initiate oxygen therapy A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all. A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temp. E. Discard any residual gastric contents. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, w/scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all. A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A. Increase in incisional pain B. Fever & chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst A nursing instructor is reviewing the wound healing process w/a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all. A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed w/adhesive E. Open burn area A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera protruding. Which of the following interventions is appropriate? Select all. A. Cover the area w/saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abd. C. Use sterile gloves to apply gentle pressure to the exposed tissues D. Position the client supine w/his hips & knees bent E. Offer the client a warm beverage, such as herbal tea A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all. A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences often C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least Q 3 hr while in bed [Show More]

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