Exam #3 ATI Flashcards
(40 cards)
A nurse enters a client’s room and finds him sitting in his chair. He states, “I fell in the shower, but I got myself back up and into my chair.” How should the nurse document this in the client’s chart?
A. The client fell in the shower
B. The client states he fell in the shower and was able to get himself back into the chair
C. The nurse should not document this info in the chart because she did not witness the fall
D. The client fell in the shower but is now resting comfortably
B. The client states he fell in the shower and was able to get himself back into his chair
A nursing instructor is reviewing documentation with a group of nursing students. Which of the following legal guidelines should they follow when documenting in a client’s record?
(Select all that apply)
A. Cover errors with correction fluid, and write in the correct info
B. Put the date and time on all entries
C. Document objective data, leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of the shift to document
B. Put the date and time on all entries
C. Document objective data, leaving out opinions
A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report?
A. The client’s input and output for the shift
B. The client’s blood pressure from the previous day
C. A bone scan that is scheduled for today
D. The med routine from the MAR
C. A bone scan that is scheduled for that day
A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply)
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the phone Rx
C. Obtain the prescriber’s signature on the prescription within 24 hr
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by phone
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the phone Rx
C. Obtain the prescriber’s signature on the prescription within 24 hr
A nurse on a med-surg unit has received change-of-shift report and will care for four 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 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who was
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
C. Reapplying a condom catheter for a client who has urinary incontinence
A nurse is delegating the ambulation of a client who had knee arthroplasty five days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply)
A. The roommate is up independently
B. The client ambulate’s with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain medication 30 minutes ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning
B. The client ambulate’s with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain medication 30 minutes ago
The RN is making assignments for client care to a licensed practical nurse at the beginning of the shift. Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hour post operative 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 into being on a patient-controlled analgesia (PCA) pump?
D. Replacing the cartridge into being on a patient-controlled analgesia (PCA) pump?
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply) A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances
B. Right supervision/evaluation
C. Right direction/communication
E. Right circumstances
A nurse manager of a medical surgical unit is assigned care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following the Thoracic surgery. To which staff member should the nurse assigned to this client? A. Charge nurse B. RN C. LPN D. Assistive personnel (AP)
B. RN
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to his room B. Conduct a client care conference C. Review the clients medical orders D. Develop a plan of care
A. Orient the client to his room
A nurse is admitting a client who has acute cholecystitis to a medical surgical unit. Which of the following actions are essential steps of the admission procedure?
A. Explain the roles of other care delivery staff
B. Begin discharge planning
C. Provide information about advance directives
D. Document the clients wishes about organ donation
E. Introduce the client to his roommate
A. Explain the roles of other care delivery staff
B. Begin discharge planning
C. Provide information about advance directives
E. Introduce the client to his roommate
A nurse is transferring a client from an acute care hospital to a rehabilitation facility. Which of the following information about the client should the nurse include in the transfer report? (Select all that apply) A. Alert and oriented B. Refuses to eat spinach C. Has a shellfish allergy D. Requests morphine every 4 hr E. Missed the two cats he has at home
A. Alert and oriented
C. Has a shellfish allergy
D. Requests morphine every 4 hr
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply)
A. Advance directive status
B. Where to go for follow-up care
C. Instructions for diet and meds
D. Most recent vital sign data
E. Contact info for the home Health care agency
B. Where to go for follow-up care
C. Instructions for diet and meds
E. Contact info for the home health care agency
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family? A. BMI B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing
D. Any difficulty swallowing
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?
A. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
B. “it’s been so stressful for me to have to depend on my son to help around the house.”
C.”I just heard my friend Al died. That’s the third one in three months.”
D. “I keep forgetting which medications I have taken during the day.”
D. “I keep forgetting which medications I have taken during the day”
A nurse is admitting an older adult client who has lost 4.5 kg since his last admission six months ago. Which of the following questions should the nurse ask to investigate the source of his weight loss? (Select all that apply)
A. “Do you eat alone or with someone?”
B. “Do you watch tv while eating your meals?”
C. “Have you started any new meds in the past 6 months?”
D. “What foods have you eaten within the past 24 hr?”
E. “Are you on a fixed income?”
A. “Do you eat alone or with someone?”
C. “Have you started any new meds in the past 6 months?”
D. “What foods have you eaten within the past 24 hr?”
E. “Are you on a fixed income?”
A nurse is planning a presentation to a group of older adults at a senior community center about the essential screening tests and preventive procedures during this stage of life. Which of the following should the nurse include? (Select all that apply)
A. HPV immunization
B. Pneumococcal immunization
C. Eye exam
D. Mental health screening
E. Dual-energy x-Ray absorptiometry (DEXA) scanning
B. Pneumococcal immunization
C. Eye exam
D. Mental health screening
E. Dual-energy x-Ray absorptiometry (DEXA) scanning
A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply)
A. Increase iron intake to prevent anemia
B. Decreased fluid intake to prevent urinary incontinence
C. Increase calcium intake to prevent osteoporosis
D. Limit sodium intake to prevent edema
E. Increase fiber intake to prevent constipation
C. Increase calcium intake to prevent osteoporosis
D. Limit sodium intake to prevent edema
E. Increase fiber intake to prevent constipation
A nurse is collecting data from an older adult client as part of a comprehensive physical exam. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity
B. Decreased height
D. Nail thickening
E. Decreased bladder capacity
A nurse is using an interpreter to communicate with a client. Which of the following are appropriate when communicating with a client and his family? (Select all that apply.)
A. Talk to the interpreter about the family while the family is in the room
B. Ask the family one question at a time
C. Look at the interpreter when asking the family questions
D. Use lay terms if possible
E. Do not interrupt the interpreter and the family as they talk
B. Ask the family one question at a time
D. Use lay terms if possible
E. Do not interrupt the interpreter and the family as they talk
A nurse is caring for a client who shares the same religious background. The nurse should recognize that:
A. Members of the same religion share similar feelings about their religion
B. A shared religious background generates mutual Overgaard for one another
C. The same religious believes may influence individuals differently
D. They should discuss the differences and commonalities in their beliefs
C. The same religious believes may influence individuals differently
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions is appropriate for the nurse to take?
A. Contact the hospital’s spiritual services
B. Ask him what is making him cry
C. Provide quiet times for these moments
D. Turn on the television for a distraction
C. Provide quiet times for these moments
A nurse is planning care for a client who is a devout Muslim and is three days postoperative following hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the Muslim client?
A. “I will make sure the menu includes kosher options.”
B. “I will discuss the daily schedule with the client to make sure the client will have time for prayer.”
C. “I will make sure to use direct eye contact when speaking with this client.”
D. “I will make sure daily communion is available for this client.”
B. “I will discuss the daily schedule with the client to make sure the client will have time for prayer.”
A nurses caring for a client who is Jehovah’s Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion in. Which of the following responses by the nurse is appropriate?
A. “I believe in this case you should really make an exception and accept the blood transfusion.”
B. “I know your family would approve of your decision to have a blood transfusion.”
C. “why does your religion mandate that you cannot receive any blood transfusions?”
D. “let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
D. “let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
