PRATCTICE RN Fundamentals Online Practice 2019 B PDF

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NURSING ATI RN FUNDAMENTAL PART B 2019
Practice exam to test your knowledge, has the right answer to each questions....

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RN Fundamentals Online Practice 2019 B 1. 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? Answer: Have family members wear a gown and gloves when visiting. Rationale: 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. 2. 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? Answer: Breath sounds Rationale: 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. 3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? Answer: Ambulating a client who is postoperative Rationale: 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. 4. A nurse enters a client’s room and finds her 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? My answer: “Client was trying to get out of bed.” Answer: "Client found lying on floor." Rationale: 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. 5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Answer: Cleanse the wound from the center outward. Rationale: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. The nurse should wear clean gloves to remove the old dressing, not sterile gloves. The nurse should warm the irrigation solution to body temperature. The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation. 6. A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? My answer: Airborne Answer: Droplet Rationale: 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. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.

7. A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.) Answer: Check the cord routinely for frays or tearing; consider purchasing a generator for power backup; observe for signs of hypoxia Rationale: Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia. 8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following items should the nurse plan to document on the client’s intake and output record as 120 mL of fluid? Answer: 8 oz of ice chips Rationale: The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. 9. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) Answer: Place the client in a room with negative-pressure airflow; wear gloves when assisting the client with oral care; use antimicrobial sanitizer for hand hygiene Rationale: The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. 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. 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. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions. 10. 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? Answer: Withhold the blood transfusion. Rationale: The principle of autonomy ensures that a client who is competent has the right to refuse treatment. 11. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? My answer: "I will make sure the shoulder rests are snug against my armpits." Answer: "When descending stairs, I will first shift my weight to my right leg."

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Rationale: To descend stairs, the client should first shift his body weight to his right, unaffected leg. To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae. Just before sitting down, the client should hold both crutches by their hand bars in one hand. The client should place his crutches 15 cm (6 in) in front and to the side of each foot. A nurse has accepted a verbal prescription “for three tenths of a milligram of levothyroxine IV stat” for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client’s medical record? Answer: 0.3 mg Rationale: The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Answer: Bladder scan shows 525 mL of urine. Rationale: 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 assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? Answer: Erythema on pressure points Rationale: Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. 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? Answer: Tell the client to keep the head of the bed elevated at least 30°. Rationale: 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 on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? My answer: Evaluate the client's ability to self-administer medications. Answer: Compare prescriptions with medications the client received while at the facility. Rationale: When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge. 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? Answer: "I flushed what I urinated at 7:00 a.m. and have saved all urine since."

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Rationale: For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. 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? Answer: "You should receive a pneumococcal vaccine when you are 65 years old." Rationale: 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 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 except? Answer: Rapid heart rate Rationale: Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. A client's urine specific gravity is greater than 1.030 in the presence of fluid volume deficit. Hypotension is an expected finding for a client who has fluid volume deficit. A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA ) pump. Which of the following actions should the nurse take? Answer: Instruct the family to refrain from pushing the button for the client while she is asleep. Rationale: 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. The nurse should monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. The client is at risk for respiratory depression as a result of opioid medication administration. The nurse should instruct the client to activate the PCA pump when she needs it. It is inappropriate for the client to wait until pain escalates to any particular level of intensity before using the pump. A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at increased risk for hypertension? Answer: A client who smokes one pack of cigarettes each day Rationale: A client who smokes one pack of cigarettes each day is at an increased risk for hypertension. Clients who are 60 years of age or older are at an increased risk for hypertension. A nurse in a clinic is caring for a middle adult client who states, “The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?” Which of the following responses should the nurse make? My answer: "Beginning at age 60, you should have a colonoscopy." Answer: "You should have a fecal occult blood test every year." Rationale: Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually. Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client’s neck, the nurse hears the following sound. This sound indicates which of the following?

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Answer: Narrowed arterial lumen Rationale: Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? Answer: Initiate an enteral feeding through a gastrostomy tube. Rationale: It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of the assistive device? Answer: "I will be sure to remove my hearing aid before taking a shower." Rationale: Clients should remove any hearing devices before showering because exposure to water can damage them. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client’s risk of developing plantar flexion contractures? My answer: Place a pillow under the client's knees. Answer: Apply an ankle-foot orthotic device to the client's feet. Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. The nurse should place a pillow under the client's lower legs to prevent pressure on the heels. A nurse in a surgical suite notes documentation on a client’s medical record that he has a latex allergy. In preparation for the client’s procedure, which of the following precautions should the nurse take? Answer: Wrap monitoring cords with stockinette and tape them in place. Rationale: 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 home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? Answer: The caregiver insists on remaining in the room. Rationale: A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. a nurse is administering IV fluid to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? Answer: Auscultate lung sounds. Rationale: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess,

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a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? Answer: 122 mm Hg Rationale: To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Answer: The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin. a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Answer: Walking briskly Rationale: Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. A nurse is caring for a client who ahs a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? Answer: "We can talk about advance directives, and I can also give you some brochures about them." Rationale: With this statement, the nurse offers to provide the information the client needs in a direct and simple way. A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? Answer: A client who has asthma Rationale: Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma. 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?

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Answer: "I can take echinacea to improve my immune system." Rationale: Echinacea is taken to promote immunity and reduce the risk of infection. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? Answer: Gently shake the container of medication prior to administration. Rationale: The nurse should gently shake the liquid medication to ensure that the medication is mixed. The nurse should place the client in high-Fowler's position when administering an oral liquid medication to reduce the risk of aspiration. The nurse should not transfer prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which o...