ATI Content Mastery Series Questions with Complete Verified Solutions 2024/2025, Exams of Nursing

Download ATI Content Mastery Series Questions with Complete Verified Solutions 2024/2025 and more Exams Nursing in PDF only on Docsity! ATI Content Mastery Series Questions with Complete Verified Solutions 2024/2025 A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers A, B, D - Correct: Restorative health care involves intermediate follow-up care for restoring health and promoting self-care. C-Incorrect: Diagnostic centers are a type of secondary health care. Secondary health care includes the diagnosis and treatment of acute injury or illness. E- Incorrect: An oncology center is a type of tertiary health care. Tertiary health care is specialized and highly technical care. A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid B, E- Correct: Medicare and Medicaid are federally funded. A, C, D - Incorrect: PPOs, Long-term care insurance, and EPOs are privately funded. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits. B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. C. Providing specialized intraoperative training in surgical treatments for obesity. D. Educating acute care nurses about postoperative complications related to obesity. A- Correct: Identify obesity screenings at office visits as an example of primary health care. Primary health care emphasizes health promotion and disease control. B- Incorrect: Rehabilitation care is an example of restorative health care. C- Incorrect: Specialized and highly technical care is an example of tertiary health care. D- Incorrect: Acute care is an example of secondary health care. A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients B- Correct: Identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations A.- Incorrect: Identify that utilization review committees have the responsibility of monitoring for appropriate diagnosis and treatment according to evidence-based practice. C- Incorrect: Identify that the Joint Commission has the responsibility of setting quality standards for accreditation of health care facilities D-Incorrect: Identify that the U.S FDA has the responsibility of determining whether medications are safe for administration to clients. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) A. Intensive care unit B. Oncology treatment center E- Incorrect: Although some analgesics can cause respiratory depression, requiring assistance from a respiratory therapist is not within this therapist's scope of practice to counsel the client about medications prescribed by the provider. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist D- Correct: A speech-language pathologist can initiate specific therapy for clients who have difficulty with feeding due to the swallowing difficulties. A- Incorrect: A social worker can coordinate community services to help the client, but not specifically with dysphagia. B- Incorrect: A certified nursing assistant can help the client with feeding, but cannot assess and treat dysphagia. C- Incorrect: An occupational therapist can assist clients who have motor challenges to improve abilities with self-care and work, but cannot assess and treat dysphagia. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determing pain level E. Measuring vital signs A, B, C, E- Correct: It is within the range of function for a CNA to provide basic care (bathing, ambulation, toileting, and measuring and recording vital signs) to clients. D- Incorrect: Determining pain level is a task that requires the assessment skills of licensed personnel (nurses) and is outside the range of function for a CNA Describe at least five (5) types of advance practice nursing roles, including a brief description of their primary responsibilities. 1. Clinical nurse specialist (CNS): Typically specializes in a practice setting or a clinical field. 2. Nurse practitioner (NP): Collaborates with one or more providers to deliver nonemergency primary health care in a variety of settings. 3. Certified registered nurse anesthesiologist (CRNA): Administers anesthesia and provides care during procedures under the supervision of an anesthesiologist. 4. Nurse educator: Teaches in schools of nursing, facilities, or client education departments. 5. Nurse administrator: Provides leadership to nursing departments within a health care facility. 6. Nurse researcher: Conducts research primarily to improve the quality of client care. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence B- Correct: In this situation, the client is exercising their right to make their own personal decision about surgery, regardless of others' opinions of what is "best" for them. This is an example of autonomy. A- Incorrect: Fidelity is the fulfillment of promises. The nurse has not made any promises, this is the client's decision. C- Incorrect: Justice is fairness in care delivery and in the use of resources. Because the client has chosen not to use them, this principle does not apply. D- Incorrect: Nonmaleficence is a commitment to do no harm. In this situation, harm can occur whether or not the client has surgery. However, because they choose not to, this principle does not apply. A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence D- Correct: Beneficence is action that promotes good for others, without any self-interest. By administering pain medication before the client attempts a potentially painful experience like ambulation, the nurse is taking a specific and positive action to help the client. A- Incorrect: Fidelity is the fulfillment of promises. Unless the nurse has specifically promised the client a pain-free recovery, which is unlikely, this principle does not apply. B- Incorrect: Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. In this situation, this nurse delivering responsible care, the principle does not apply. C- Incorrect: Justice is fairness in c are delivery and in the use of resources. Pain management is available for all clients who are postoperative, so this principle does not apply. A nurse in instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence C- Correct: Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. A- Incorrect: Fidelity is the fulfillment of promises. No one can promise anyone an organ. B- Incorrect: Autonomy is the right to make personal decisions, even when they are not necessarily in ther person's best interest. D- Incorrect: Nonmaleficence is a commitment to do no harm. In this situation, harm can occur to organ donors and to recipients. The requirements of the organ procurement organizations are standard procedures and do not address avoidance of harm or injury. A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the ethical principles? A. Fidelity B. Autonomy D- Incorrect: the nurse has not disclosed any protected health information, so there is no breach of confidentiality involved. A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of 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 with 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." C- Correct: The client has the right to decide and specify which medical procedures he wants when a life- threatening situation arises. A- Incorrect: The client can designate any competent adult to be his health care proxy. it does not have to be his spouse. B- Incorrect: The hospital staff must ask the client whether he has prepared advance directives and provide written information about them if he has not. The nurse should document whether the client has signed the advance directives. The hospital staff cannot refuse care based on the lack of advance directives. D- Incorrect: The client does not need his provider's approval to submit his advance directives. However, he should give his primary care provider a copy of the document for his records. A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) 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, B- Correct: It is the nurse's responsibility to verify and witness that the surgeon obtained the client's consent, the client understands the information the surgeon gave them, and the client is consenting voluntarily and appears to be competent to do so. C, D, E- Incorrect: It is the surgeon's responsibility to explain the risks and benefits, describe the consequences of choosing not to have the surgery, and to tell the client about any available 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. Alert the American Nurses Association B. Fill out an incident report C. Report the observation to the nurse manager on the unit D. Leave the nurse alone to sleep. C- Correct: Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager. A- Incorrect: Do not alert the American Nurses Association. The state's board of nursing regulates disciplinary action and can revoke a nurse's license for substance use. B- Incorrect: Do not fill out an incident report. Incident reports are filed to document an accident or unusual occurrence. D- Incorrect: Do not leave the nurse alone to sleep. Although the nurse is not responsible for solving the problem, she does not have a duty to take action because she has observed the problem. List the five (5) elements necessary to prove negligence and at least four (4) ways nurses can avoid liability for negligence. Proving negligence: 1. Duty to provide care as defined by a standard 2. Breach of duty by failure to meet standard 3. Forseeability of harm 4. Breach of duty has potential to cause harm 5. Harm occurs Nursing interventions: 1. Following standards of care 2. Giving competent care 3. Communicating with other health team members 4. Developing a caring rapport with clients 5. Fully documenting assessments, interventions, and evaluations A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? A. Input and Output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record C- Correct: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit. A, B, D - Incorrect: Unless there is a significant change in the intake and output, blood pressure, or medication routine, the oncoming nurse can read that information in the chart. A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur a the nurses' station D. A client can request a copy of their medical record E. A nurse can photocopy a client's medical record for transfer to another facility. B, C, D, E- Correct: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. A- Incorrect: The HIPAA Privacy Rule requires the protection of clients' electronic records. The rule states that electronic records must be password-protected and each staff should use an individual password to access information. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. 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, C- Correct: Documentation must confirm correct sequence of events for day and time and be factual, descriptive, and objective, without opinions or criticism. A- Incorrect: Correction fluid implies that the nurse might have tried to hide the previous documentation or deface the medical record. D- Incorrect: Too many abbreviations can make the entry difficult to understand. Nurses should minimize B- Correct: A client who is postoperative following thoracic surgery requires professional nursing knowledge, skills, and judgement of an RN to provide safe and effective client care. A- Incorrect: Although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs. C, D- Incorrect: A client who is postoperative following thoracic surgery requires professional nursing knowledge, skills, and judgement that is outside the range of function of a PN and AP. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days afo to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 mins ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning. B, C, D- Correct: To complete this assignment safely, the AP should make sure the client wears stocking and slippers, uses a front-wheeled walker, and know that the client should be feeling the effects of the pain medication. A, E, F- Incorrect: The AP does not need to know the status of the client's roommate, the client's allergy status, or the client's food intake to complete the assignment. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client who is recovering following a stroke. B. Assessing a pressure injury on the client who is on bed rest. C. Providing nasopharyngeal suctioning for a client who has pneumonia. D. Teaching a client who has asthma to use a metered-dose inhaler (MDI). C- Correct: Providing nasopharyngeal suctioning is within the scope of practice of the PN. A, B, D- Incorrect: Creating a plan of care, Assessing a pressure injury, and Teaching clients requires professional nursing knowledge, skills, and judgement of an RN. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances B, C, E- Correct: The right to supervision and evaluation, right direction and communication, and right circumstances are part of the five right of delegation, including right task, and right person. A, D- Incorrect: Right route and right documentation are part of the rights of medication administration. List at least five (5) tasks the delegating nurse must perform when supervising and evaluating a delegatee. * Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse) * Monitor performance * Intervene if necessary (for unsafe clinical practice) * Provide feedback > Did the delegatee complete the task(s) on time? > Was the delegatee's performance satisfactory? > Did the delegatee document and report unexpected findings? > Did the delegatee need help completing the task(s) on time? * Evaluate the client and determine the client's outcome status * Evaluate task performance and identify needs for performance-improvement activities and additional resources By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain. A- Correct: Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care. B- Incorrect: Do not wait longer to see how the client would respond, but take action to determine why the client is not achieving satisfactory pain relief. C- Incorrect: Do not make random changes to the plan of care without gathering evidence to guide the nurse in knowing what new interventions might help. D- Incorrect: The action does not acknowledge the client's condition or that the current plan is ineffective. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted that the last dose of pain medication was 6hrs ago. The prescription reads every 4hr PRN for pain. The nurse administered the medication and checked with the client 40 mins later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A.. Assessment B. Planning C. Intervention D. Evaluation A- Correct: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 pain scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain. B- Incorrect: The newly licensed nurse used the planning step of the nursing process when deciding that it was the right time to administer the medication. C- Incorrect: The newly licensed nurse used the implementation step of the nursing process when administering the medication. D- Incorrect: The newly licensed nurse used the evaluation step of the nursing process when checking the effectiveness of the pain medication. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations B. The client's partner states, "They said they hurt after walking about 10 mins." C. The client's pain rating is 3 on a scale of 0 to 10. D. The client's skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp. A. Fairness B. Responsibility C. Risk-taking D. Creativity B- Correct: The nurse is responsible for administering medication in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety. A- Incorrect: Fairness is using a nonjudgmental, objective approach in looking at clients and situations. C- Incorrect: Risk-taking is a calculated approach to solving a problem that is not responding to traditional methods. D- Incorrect: Creativity is an approach that uses imagination to find solutions to unique client problems. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) A. Find a mentor B. Use a journal to write about the outcomes of clinical judgments C. Review articles about evidenced-based practice D. Limit consultations with other professionals involved in a client's care E. Make quick decisions when unsure about a client's needs. A- Correct: Learning from the experience of peers can improve critical thinking. B- Correct: Journaling about decision-making can assist the nurse with self-reflections and improve critical thinking C- Correct: Improving knowledge by learning new information about evidenced-based practice improves the nurse's ability to think critically. D- Incorrect: Although nurses who have advanced critical thinking can do so independently, the nurse should talk to other professionals to share information and remain open-minded and inquisitive. E- Incorrect: Quick decision-making can lead to errors. A nurse's intuition might cause feelings of uncertainty, which should lead the nurse to ask questions about whether the plan of care makes sense and to gather more information. A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence A- Correct: By using the electronic database, the nurse takes the initiative to increase their knowledge base, which is the first component of critical thinking. B- Incorrect: The nurse has had no prior experience with administering this medication on this client. C- Incorrect: Intuition requires experience, which the nurse lacks in administering this medication to this client. D- Incorrect: Competence involves making judgments, but no one can make a judgment about how the nurse handles researching and administering this medication to this client until they perform those tasks. A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline D- Correct: Discipline includes using a systematic approach to thinking. Using a head-to-toe approach ensures the nurse in thorough and calculated in getting information about the client's physical status. A- Incorrect: Confidence is feeling sure of one's own abilities. The nurse might feel confident of their physical assessment skills, but choosing a particular method or sequence requires another attitude. B- Incorrect: Perseverance is continuing to work at a problem until the nurse resolves it. C- Incorrect: Integrity is practicing truthfully and ethically. List three (3) critical thinking skills for each of the five steps of the nursing process. * Assessment/ Data collection > Observe > Use correct techniques for collecting data > Differentiate b/t relevant and irrelevant data and b/t important and unimportant data > Organize, categorize, and validate data > interpret assessment data and draw a conclusion * Analysis/Data collection > Identify clusters and cues > Detect inferences > Recognize an actual or potential problem or risk > Avoid making judgments * Planning > Identify goals and outcomes for client care > Set priorities > Determine appropriate strategies and interventions > Take knowledge and apply it to more than one situation > Create outcome criteria > Theorize > Consider the consequences of imiplementation * Implementation > Use knowledge base > Use appropriate skills and teaching strategies > Test theories > Delegate and supervise nursing care > Communicate appropriately in response to a situation * Evaluation > Determine accuracy of theories > Evaluate outcomes based on specific criteria > Determine understanding of teaching A nurse is performing an admission assessment for an older 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 their room B. Conduct a client care conference C. Review medical prescriptions D. Develop a plan of care A- Correct: The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside. B, C, D- Incorrect: Another action is the priority 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? (Select all that apply.) sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound D. Keep a box of facial tissue nearby for the client to use during the dressing change. C- Correct: Placing a mask on the client prevents contamination of the surgical wound during the dressing change. A- Incorrect: It would be difficult for to maintain a sterile field away from the bedside. But more important, this might not have any effect on the transmission of some micro-organisims. B- Incorrect: The client might be unable to refrain from coughing and sneezings during the dressing change. D- Incorrect: Keeping tissues close by for the client to use still allows contamination of the surgical wound A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body D- Correct: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from her body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it. A- Incorrect: The flap closest to the body is in the innermost flap and the last one to unfold. B, C- Incorrect: Unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap to unfold first. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand C, D - Correct: Any objects (incl. inner wrappings of objects) dropped onto the sterile field are sterile. touch them with sterile gloves. E- Correct: one sterile gloved hand may touch the other sterile gloved hand b/c both are sterile. A- Incorrect: A bottle of sterile solution is sterile on the inside and non-sterile on the outside. Prepare the sterile container of solution on the field before putting on sterile gloves. B- Incorrect: The 1-inch border at the outer edge of the sterile field is not sterile. Do not touch it with sterile gloves. A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing. B- Correct: this is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. D- Correct: If the sink does not have a foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands. A- Incorrect: the APs should apply alcohol rubs to dry hands and wet the hands first before applying soap for handwashing. C- Incorrect: The APs should use warm water to minimize the removal of protective skin oils. E- Incorrect: The APs should dry their hands with a clean paper towel. This helps prevent chapped skin. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr b/c the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field. B- Correct: Fluid permeation of the sterile drape or barrier contaminates the field. C- Correct: Prolonged exposure to air contaminates a sterile field. D- Correct: Turning away from a sterile field contaminates the field b/c he nurse cannot see if a piece of clothing or hair made contact with the field. A- Incorrect: As long as the provider has not reached over the sterile field (by placing the instrument on a near portion of the field), the field remains sterile. E- Incorrect: The 1-inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile. A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A, B, C, E- Correct: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies, determining public health priorities, ensuing proper medical treatment is available, and monitoring for common-source outbreaks. D- Incorrect: Endemic disease is already prevalent within a populations so reporting is not necessary. A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Tuberculosis D- Correct: A cough for 3 weeks and beginning to cough up blood are manifestations of tuberculosis. A- Incorrect: A pink body rash is a manifestation of an allergic reaction B- Incorrect: Red circles with white centers is a manifestation of ringworm. C- Incorrect: A red edematous rash bilaterally on the cheeks is a manifestation of systemic lupus erythematosus. A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. the client is experiencing which of the following stages of infection? C- Incorrect: Note the time the seizure begins, and track how long the seizure lasts. D- Place nothing in the client's mouth except an oral airway, if necessary. A tongue blade can cause injury and airway obstruction. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm C. Move the clients who are nearby. D. Close all open doors on the unite. C- Correct: The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire. A, B, D- Incorrect: Although extinguishing the fire, activating the fire alarm, and containing the fire are part of the protocol for responding to a fire, it is not the priority action. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession. A- Correct: The first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will work as a guide in implementing appropriate safety measures. B- Incorrect: Educate the client and family about fall risk factors so they can help promote client safety, but this is not the priority action. C- Incorrect: Eliminate safety hazards from the client's environment to help reduce the risk for falls, but this is not the priority action. D- Incorrect: Aids (eyeglasses, hearing aids, canes, and walkers) should be accessible to reduce the client's risk for falls, but this is not the priority action. A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the the door to the client's room. D- Correct: Place wet towels along the base of the door to the client's room to contain the fire and smoke in the room. A- Incorrect: Close all doors and windows to contain the fire. B- Incorrect: Attempt to extinguish the fire with a class A fire extinguisher, which is used for ordinary combustibles (cloth and paper). C- Incorrect: Removing all the electrical equipment is not needed, but do turn off all the electrical equipment in the client's room. Describe at least six (6) nursing responsibilities when caring for a client in either seclusion or restraints. 1. Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary. 2. Ask the client or guardian to sign a consent form. 3. Review the manufacturer's instructions for correct application. 4. Assess skin integrity, and provide skin care according to the facility's protocol, usually every 2hr. 5. Offer food and fluid. 6. Provide a means for hygiene and elimination. 7. Monitor vital signs. 8. Offer range-of-motions exercises of extremities. 9. Pad bony prominences to prevent skin breakdown. 10. Secure restraints to a movable part of the bed frame. If restraints with a buckle strap are not available, use a quick-release knot to tie the strap. 11. Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers b/t the restraints and the client. 12. Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs. 13. Conduct an ongoing evaluation of the client. A nurse is providing discharge instructions for a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. B, C, E- Correct: Remind the client to not use nail polish or other flammable material in the home. have the client place a "No Smoking" sign near the front door, and possibly on the client's bedroom door. Remind all individuals to have a fire extinguisher at home. This is especially important for a client who is receiving oxygen. A- Incorrect: Remind family members who smoke to do so outside. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A- Correct: Hypotension is a manifestation of heat stroke. B, C, D - Incorrect: Manifestations of heat stroke include tachycardia, hot, dry skin, and dyspnea. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding? A. "I will set my water heater at 130 F." B. "Once my baby can sit up, they should be safe in the bathtub." C. "I will place my baby on their stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib." C- Incorrect: In the semi-prone or Sims' position, the client is on their side halfway b/t lateral and prone positions. this position is not safe b/c it promotes regurgitation. D- Incorrect: In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe b/c it promotes regurgitation. A nurse is caring for a client who is sitting in a chair and asks to return to bed . Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer belt and assist the client back into bed. D. Determine the client's ability to help with the transfer. D- Correct: The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client's ability to help with transfers and then proceed with a safe transfer. A, B, C- Incorrect: Although necessary an assistive device for the client, calling for asistance, or using a transfer belt, is not the priority action the nurse should take. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with your head and shoulders supported by a pillow." B. "Have your head turned to the side while you lie on your stomach." C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D. "Lie on your side with your top arm resting on the bed and your weight on your hip." C- Correct: This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD. A- Incorrect: The nurse is describing the supine position not the orthopneic position. B- Incorrect: The nurse is describing the prone position. D- Incorrect: The nurse is describing the lateral or side-lying position. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles. A, B, D- Correct: Guidelines to injury prevention include: Two staff members should reposition clients, avoid twisting your spine or bending at the waist, and use smooth movements when lifting and moving clients. C, E- Incorrect: It is important when sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than your hips to decrease strain on the lower back as well as take a break every 15 to 20 mins not every 2 to 3 hours, from repetitive movements to flex and stretch joints and muscles. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward." B, C, D- Correct: Proper body mechanics includes: adjusting your center of gravity closer to the ground, with feet apart for increased stability and balance and holding the object as close to your body as possible to avoid displacement of center of gravity. A, E- Incorrect: The line of gravity should fall within the base of support not outside and to promote stability, move the rear leg back when pulling on an object. A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head. C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia C- Correct: A client who has burns to the face, neck, and chest is at risk for airway obstruction and requires immediate intervention for survival. Using the survival approach to client care, the nurse should give priority to this client. A- Incorrect: A client who has crush injuries to the chest and abdomen has minimal chance of survival even with intervention. The nurse should provide comfort measures for this client. B- Incorrect: A client who has a laceration to the head does not have an immediate threat to life and can wait for tx. D- Incorrect: A client who has major fractures does not have an immediate threat of life and can wait for tx. A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) A. Open doors to client rooms B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms. B, C, D- Correct A- Incorrect: Close all doors to minimize the threat of flying glass and debris E- Incorrect: Instruct ambulatory clients to go to the hallways, away from windows, or other secure location designated by the facility. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Wash the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive C- Correct A, B, D- Incorrect: Do not apply water to a dry chemical exposure b/c it could activate the chemical and cause further harm; Wash the skin with antibacterial soap in the event of a biological exposure; Plan to remove the client's clothing following decontamination. A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."