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RN ATI concept-based assessment, proctored exam 2025 for level 1 Test Bank. (Answered) Wit, Exams of Nursing

University College of London (UCL)Nursing

RN ATI concept-based assessment, proctored exam 2025 for level 1 Test Bank. (Answered) With Rational RN ATI concept-based assessment, proctored exam 2025 for level 1 Test Bank. (Answered) With Rational

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RN ATI concept-based assessment,
proctored exam 2025 for level 1 Test Bank.
(Answered) With Rationales
ATI RN Concept based assessment level
1
1. A nurse is admitting a client who has pulmonary tuberculosis. Which of
the following transmission-based precautions should the nurse initiate?
•Airborne
•Rationale: Pulmonary tuberculosis is an infection that is transmitted by
airborne droplets smaller than 5 microns in diameter. Therefore, this
client requires airborne precautions to prevent communicating this
infection to others
2. A nurse in a mental health facility is preparing an educational program for a
group of staff nurses about the proper use of restraints. Which of the following
information should the nurse plan to include?
•An adult client may be in a mechanical restraint for up to 4 hours
•Rational: The nurse should specify that a client who is 18 years or older may be
in a restraint for no more than 4 hr. Children who are 9 to 17 years old are
limited to 2 hr and children who are younger than 9 years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of
the following statements should the nurse make?
•Exercise in the morning after arising
•Rationale: Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The nurse should
recommend that the client avoid exercising within 2 hr of bedtime to limit
stimulation and enhance sleep
4. A nurse is preparing to leave the room of a client who is on isolation precautions.
Which of the following actions should the nurse take when removing a tied
surgical mask?
•Remove the mask by securely holding the ties and moving it away from the face
•Rationale: The nurse should untie the bottom strings and then the top
strings. Finally, while still holding the strings, the nurse should remove the
mask from her face. This action prevents the nurse from touching the front of
the mask, which is contaminated
5. A nurse is caring for an adolescent client who is in critical condition following a
motor vehicle crash in which he was the passenger. The client's parent shouts at the
nurse, asking why her son is dying instead of the driver. Which of the following
actions should the nurse take to provide emotional support to the parent?
•Inform the parent that anger is a natural response when dealing with loss
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Download RN ATI concept-based assessment, proctored exam 2025 for level 1 Test Bank. (Answered) Wit and more Exams Nursing in PDF only on Docsity!

RN ATI concept-based assessment,

proctored exam 2025 for level 1 Test Bank.

(Answered) With Rationales

ATI RN Concept based assessment level

  1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission-based precautions should the nurse initiate? - Airborne - Rationale: Pulmonary tuberculosis is an infection that is transmitted by airborne droplets smaller than 5 microns in diameter. Therefore, this client requires airborne precautions to prevent communicating this infection to others
  2. A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse plan to include? - An adult client may be in a mechanical restraint for up to 4 hours - Rational: The nurse should specify that a client who is 18 years or older may be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are limited to 2 hr and children who are younger than 9 years old are limited to 1 hr
  3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make? - Exercise in the morning after arising - Rationale: Daily exercise has many benefits, including enhancing cardiovascular, psychological, and musculoskeletal health. The nurse should recommend that the client avoid exercising within 2 hr of bedtime to limit stimulation and enhance sleep
  4. A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask? - Remove the mask by securely holding the ties and moving it away from the face - Rationale: The nurse should untie the bottom strings and then the top strings. Finally, while still holding the strings, the nurse should remove the mask from her face. This action prevents the nurse from touching the front of the mask, which is contaminated
  5. A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the parent? - Inform the parent that anger is a natural response when dealing with loss

- Rationale: The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings

  1. A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk of developing hypertension? - African Americans

- Rationale: The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization.

  1. A nurse is documenting an assessment in a client's electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take? - Request that the AP use another computer to enter the data - Rationale: The nurse should request that the AP to go to another computer that is not in use to enter the morning blood glucose from the client. This is time- sensitive data that needs to be entered in the computer as soon as possible.
  2. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - 1.2 mL - Rationale: Ratio and Proportion - STEP 1: What is the unit of measurement the nurse should calculate? mL - STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg - STEP 3: What is the dose available? Dose available = Have 80 mg - STEP 4: Should the nurse convert the units of measurement? No - STEP 5: What is the quantity of the dose available? 0.8 mL - STEP 6: Set up an equation and solve for X. - Have/Quantity = Desired/X - 80 mg/0.8 mL = 120 mg/X mL - X = 1. - STEP 7: Round if necessary. - STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Desired Over Have - STEP 1: What is the unit of measurement the nurse should calculate? mL - STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg - STEP 3: What is the dose available? Dose available = Have 80 mg - STEP 4: Should the nurse convert the units of measurement? No - STEP 5: What is the quantity of the dose available? 0.8 mL - STEP 6: Set up an equation and solve for X. - Desired x Quantity/Have = X

- 120 mg x 0.8 mL/80 mg = X mL - 1.2 = X - STEP 7: Round if necessary. - STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Dimensional Analysis - STEP 1: What is the unit of measurement the nurse should calculate? mL - STEP 2: What is the quantity of the dose available? 0.8 mL - STEP 3: What is the dose available? Dose available = Have 80 mg - STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 120 mg - STEP 5: Should the nurse convert the units of measurement? No - STEP 6: Set up an equation and solve for X. - X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ - X mL = 0.8 mL/80 mg x 120 mg/ - X = 1. - STEP 7: Round if necessary. - STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO

  1. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 125 mL/hr - Rationale: - Follow these steps to calculate the infusion rate: - STEP 1: What is the unit of measurement the nurse should calculate? mL/hr - STEP 2: What is the volume the nurse should infuse? 1,000 mL - STEP 3: What is the total infusion time? 8 hr - STEP 4: Should the nurse convert the units of measurement? No - STEP 5: Set up an equation and solve for X. - Volume (mL)/Time (hr) = X mL/hr - 1,000 mL/8 hr = X mL/hr - X = 125 - STEP 6: Round if necessary. - STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 1,000 mL to infuse over 8 hr, it makes sense to administer 125 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride at 125 mL/hr for 8 hr.

- Pull the alarm to notify emergency services

- Rationale: Evidence-based practice indicates the nurse should first rescue and remove clients in immediate danger and then activate the alarm to notify authorities of the situation.

  1. A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include? - Smokeless tobacco provides a higher dose of nicotine than cigarettes - Rationale: Smokeless tobacco is placed in the mouth, where nicotine is then absorbed sublingually. A higher dose of nicotine is delivered with the use of smokeless tobacco compared to smoking cigarettes, because heat destroys nicotine.
  2. A nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule. Which of the following actions should the nurse take? - Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water - Rationale: The nurse should prepare simple tablets for NG administration by crushing them into a fine powder and dissolving them in at least 30 mL of warm sterile water. Cold water can cause discomfort. Sterile water eliminates the possible problem of chemicals in tap water interacting with the medication.
  3. A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the nurse how to prevent further reactions. Which of the following responses should the nurse make? - Wash your child’s exposed clothing with hot water and detergent - Rationale: The nurse should instruct the parent to wash the child's clothing in hot water and detergent after exposure to the poison ivy plant. This will remove the oil, urushiol, which causes the skin reaction.
  4. A nurse is planning care for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse include in the plan to prevent the development of a catheter-associated urinary tract infection (CAUTI)? - Secure the catheter tubing to the client’s leg - Rationale: The nurse should assess the client's need for urinary catheterization and should follow evidence-based practice to prevent or reduce the risk of CAUTI development. This includes securing the catheter tubing to the client's leg so that the catheter does not move, reducing the risk of urethral trauma and introduction of bacteria into the urinary system
  5. A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? - Compare a list of the client’s current medications with the ones he will take in long-term care - Rationale: The Joint Commission National Patient Safety Goals regarding medication reconciliation includes maintaining and communicating accurate
  1. A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue? - Cumulative Index to Nursing and Allied Health Literature (CINAHL) - The nurse should select the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to locate clinical research about health-related client care issues. CINAHL is a cumulative index that the nurse can search electronically to locate reliable data related to the specific topic being researched.
  2. A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take? - Ensure the client and the interpreter are compatible - The nurse should ensure that the client is comfortable with the interpreter. The nurse should consider the client's age, gender, and culture when using an interpreter.
  3. A nurse is planning a community health program about substance use disorders. Which of the following information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? - A healthy woman of any age should consume no more than seven drinks in a week - Recommendations for safe limits of alcohol consumption for a healthy woman include consuming no more than seven drinks in a week
  4. A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain? - Administer a beta-blocking medication to the client - Rationale: The nurse should administer a beta-blocking medication to the client. This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain.
  5. A nurse is developing a plan of care for an older adult who is experiencing functional incontinence following hip arthroplasty. Which of the following interventions should the nurse include? - Place grab bars by the toilet - Rationale: The nurse should place grab bars by the toilet and install a raised toilet seat. These aid the client in reaching and sitting on the toilet, decreasing the chance of incontinence.
  6. A nurse is preparing to administer morphine 5 mg IM form a 10 mg/mL vial to help manage a client's acute pain. Which of the following actions should the nurse plan to take after administering a controlled substance? - Have the second nurse witness and initial the disposal of the remaining medication

- When nurses administer a portion of a vial's amount of a controlled substance, they must discard the rest safely, such as by injecting it out of the syringe into a sink or toilet, while a second nurse witnesses the first nurse discarding it. The second nurse must then initial the waste of the medication in the client's medication administration record.

  1. A nurse is preparing to administer a medication via intermittent IV bolus to a client who is receiving a continuous infusion via an infusion pump. The client's IV fluid solution is incompatible with the bolus. Which of the following actions should the nurse plan to take first? - Stop the continuous IV infusion - Rationale: According to evidence-based practice, the nurse should first stop the continuous IV infusion. This action prevents the solution from flowing through the tubing while the nurse administers the medication. An infusion pump will alarm if the tubing is clamped before the pump is stopped
  2. A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks the preschooler, "Why is it wrong for you to kick your baby sister?" Which of the following responses should the nurse expect? - It’s wrong because my dad said I can’t kick her - Rationale: The nurse should expect the preschooler to be motivated to choose right from wrong because of rules taught to him by his parents. The nurse should understand that, even though the preschooler might know the rules, he is not yet able to understand the rationale for the rules.
  3. A nurse is planning care for a client who has bacterial meningitis caused by Haemophilus influenza. Which of the following infection control interventions should the nurse include in the plan? - Place a mask on the client during transport out of the room - Rationale: The nurse should implement droplet precautions and standard precautions when caring for a client who has bacterial meningitis caused by H. influenza. The nurse should avoid transporting the client out of the room, if possible. However, if transport is necessary, then placing a mask on the client is an effective infection control intervention.
  4. A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the client's preferences into a sleep promotion plan? - Sleep in the location of your home where you feel you rest best - Rationale: The nurse should encourage the client to sleep wherever she feels she gets the most rest, whether it be a bed, couch, or chair.
  5. A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. Which of the following statements should the nurse include in the teaching? - "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies."

- The nurse should expect a preschooler who has a UTI to experience abdominal pain. Other manifestations include constipation, dysuria, foul- smelling urine, and fever.

  1. A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? - Observe the client ambulating a distance of 3 m (10 feet) during the TUG test. - Rationale: The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. The nurse should observe the client's ability to perform the test and use a stopwatch to time the client. The nurse should identify that the client is at increased risk of falls if it takes longer than 14 seconds to complete the test.
  2. A nurse is reviewing the medication administration record of a client who is 2 days postoperative following abdominal surgery. The nurse should identify that which of the following medications can result in delayed wound healing? - Prednisone - The nurse should identify that taking prednisone can result in delayed wound healing. Prednisone is a corticosteroid used in the treatment of inflammatory disorders. It can mask the manifestations of infection due to its ability to impair the inflammatory response. Other medications, such as anticoagulants and broad-spectrum antibiotics, can also play a role in delayed wound healing.
  3. A nurse is talking with a client who reports difficulty adjusting to the death of her partner. Which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting? - What do you think would help you cope with your loss? - The nurse uses the technique of reflecting when asking this question. Reflecting encourages the client to explore her personal thoughts about a situation so that a plan can be developed to meet the client's individual needs
  4. A nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric surgery. Which of the following dietary recommendations should the nurse make? - Eats foods that are high in protein - The nurse should recommend that the client increase protein intake to promote healing from surgery. A client who is 3 days postoperative following bariatric surgery should limit foods to clear and full liquids. The nurse should recommend food items such as Greek yogurt. This full-liquid food also meets the dietary requirement for protein-rich foods.
  5. A nurse in a provider's office is caring for a male client who just turned 50 years old. The client has no significant health problems or family history of health problems. Which of the following preventive health screenings should the nurse recommend?

- Initial screening colonoscopy: Current guidelines recommend that clients who are age 50 years and older receive an initial screening for colon and rectal cancer, such as with a colonoscopy. Subsequent screenings should be scheduled depending on the results. - Digital rectal examination: Current guidelines recommend that male clients who are age 50 years and older have a yearly digital rectal examination to screen for prostate cancer. The client should also have his prostate-specific antigen level checked annually - Monthly testicular self-examination (TSE): Current guidelines recommend that clients who are age 15 years and older perform a monthly TSE to screen for testicular cancer. The nurse should encourage the client to continue this preventive screening - Annual skin examination: Current guidelines recommend that clients who are age 40 years and older receive an annual skin examination to screen for skin cancer. If a suspicious lesion is detected, a biopsy should be performed.

  1. A nurse is using therapeutic communication to attempt de-escalation with a client who is yelling at staff members. Which of the following statements should the nurse make? - Tell me wat is causing your anger at this moment - Rationale: This statement uses the therapeutic communication technique of exploring, which promotes client communication. Exploring and the use of open- ended statements encourage the client to talk about his feelings and emotions at this time. Talking about his feelings can help the client calm down, and the information is used to help prevent further episodes of anger.
  2. A charge nurse is observing a newly licensed nurse prepare medications for a client. Which of the following actions by the newly licensed nurse adheres to safe medication administration practices? - The nurse compares the medication label with the client’s medication administration record - When preparing medications for administration, safe practice includes comparing the medication label with the client's medication administration record a minimum of three times: prior to removing the medication from the drawer, when removing medication from the drawer, and at the client's bedside prior to administering the medication.
  3. A nurse is caring for a child who has celiac disease. Which of the following items should the nurse remove from the child's meal tray? - Oatmeal with raisins - Rationale: Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats, and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue. Therefore, the nurse should remove oatmeal from the child's meal tray.
  4. A newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. Which of the following responses should the charge nurse make?

- Postherpetic neuralgia pain: Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Postherpetic neuralgia pain is a type of neuropathic pain. - Phantom limb pain: Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Phantom limb pain is a type of neuropathic pain - Spinal nerve pain: Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Spinal nerve pain is a type of neuropathic pain.

  1. A nurse is teaching a client who is postpartum about preventing injury when using car seat for her newborn. Which of the following instruction should the nurse include? - Install the car seat so that it is facing the rear of the vehicle - Rationale: The client should install the car seat so that it is rear-facing in the back seat. This position also protects the newborn's head and neck during a sudden stop or a crash. The back of the car seat protects the newborn's spine
  2. A charge nurse is educating unit staff about the cultural aspects of client care following death. Which of the following statements by assistive personnel indicates an understanding of the teaching? - "The body of a client who practices Islam is washed and wrapped in a cloth following death." - Rationale: The body of a client who practices Islam is washed, wrapped, prayed over, and buried as soon as possible following death. The client's head should be turned toward Mecca.
  3. A nurse is providing change-of-shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include? - The client has been very tearful since finding out he had diabetes mellites - Rationale: The nurse should include significant information such as a new diagnosis in the change-of-shift report. The nurse should also identify changes in the client's emotional status that might indicate a need for additional client support and teaching.
  4. A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching? - "I can give her watermelon pieces after I remove the seeds." - Rationale: The nurse should inform the parent that toddlers can easily choke on seeds from fruits, such as watermelon seeds or cherry pits, because of their round shape and size. Removing the seeds and cutting the watermelon into pieces provides the toddler with a nutritious snack that does not increase the toddler's risk of foreign body obstruction.
  5. A nurse is assessing a client who has fibromyalgia. Which of the following treatment modality prescriptions should the nurse expect for the client's mixed pain? - Pregabalin PO twice daily

- Rationale: The nurse should expect a prescription for an antidepressant medication such as pregabalin. The mixed pain experienced by a client who has fibromyalgia has components of both nociceptive and neuropathic pain, which responds best to adjunctive treatment modalities such as antidepressants. These medications work to increase the release of serotonin and norepinephrine neurotransmitters in the brain.

  1. A nurse is caring for an older adult client who has a leg wound following a fall on the stairs. The nurse should identify which of the following factors as an exposed, age- related change in older adults that can impair wound healing? - Elastin fibers separate and thicken - The nurse should identify that elastin fibers in an older adult client thicken and separate, which can cause delayed wound healing and lead to a "saggy" appearance due to decreased skin elasticity
  2. A nurse is asked by a provider to perform an invasive procedure for which he has not received training. Which of the following actions should the nurse take to ensure that it is within his legal scope of practice to perform this procedure? - Check the state's nurse practice act before performing the procedure. - The nurse should check the state's nurse practice act to verify that performance of the procedure is within his scope of practice. This will ensure that the nurse follows legal guidelines for his scope of practice. If the nurse works in more than one state, he should check the nurse practice act for each state, because guidelines for this procedure might differ from state to state. If the procedure is within the nurse's scope of practice, he should take necessary steps to gain competence in the procedure before performing it on a client.
  3. A nurse is caring for an older adult client who has osteoarthritis and plans to go to an assisted living facility due to decreased mobility. Which of the following actions should the nurse take when acting in the role of client advocate? - Research facilities for the client that best meet her specific needs - Rationale: The nurse is acting in the role of a client advocate when identifying the client's specific needs and then advocating for those needs by researching assisted living facilities that best meet those needs. The nurse's research findings support the client's autonomy by providing her with information needed to make an informed decision when selecting a facility
  4. A nurse is teaching about advance directives with an older adult client who has a terminal illness. Which of the following statements should the nurse make? - "Your advance directives can designate a friend to make your health care decisions." - Rationale: The nurse should inform the client that he may include a health care proxy or durable power of attorney for health care as part of his advance directives. This form designates a person of the client's choosing to make health care decisions for him if he becomes unable to do so for himself. This may be a relative, personal friend, or anyone the client designates. The nurse should ensure that this form is witnessed or notarized according to state law.

- Rationale: The nurse should use a new blood infusion tubing set for each component of blood. A blood infusion set should not be reused, even for the same client.

  1. A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? - Delay the client's meal-time if he is fatigued. - Rationale: To facilitate safe swallowing and decrease the risk of aspiration, the nurse should encourage the client to rest prior to meal-time. If the client is fatigued, the nurse should delay the meal-time and give the client time to rest.
  2. A nurse is planning car for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting (CINV) during her previous round of treatment. Which of the following interventions should the nurse include in the client's plan of care? - Administer ondansetron to the client prior to chemotherapy administration. - Rationale: The nurse should incorporate evidence-based practice interventions into the client's plan of care to prevent and treat CINV. Evidence-based research indicates that prevention of CINV is best achieved when antiemetics, such as ondansetron, are given prior to the administration of chemotherapy.
  3. A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the following statements by the client indicates an understanding of the teaching? - "I should use a warm paraffin dip for my hands and feet." - Rationale: The nurse should instruct the client to dip her hands and feet in warm paraffin to alleviate pain and stiffness. The client can more easily perform hand and finger exercises following the treatment.
  4. A nurse is planning care for a newly-admitted school-age child who has rubeola. Which of the following isolation precautions should the nurse plan to initiate? - Airborne - Rationale: The nurse should initiate airborne precautions for a client who has varicella, measles (rubeola), or pulmonary tuberculosis. Airborne precautions include a private room with negative pressure airflow, with 6 to 12 air exchanges/hr via a high-efficiency particulate air (HEPA) filtration system.
  5. A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. Which of the following actions should the nurse manager take to promote interoperability? - Recommend a single coding system for each department to use - Rationale: The nurse manager should recommend a unified coding system for each department to use when documenting in the EMR system. This use of a single coding system ensures that data is shared accurately among interprofessional departments and that each department's system is able to process the coded information. This continuity of shared data and the ability to use the data is referred to interoperability.
  1. A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent gastrointestinal (GI) cancers. Which of the following images indicates a food or beverage the nurse should encourage the client to include liberally in his diet? - Fruit - Rationale: To help reduce the risk of cancers of the GI system, the nurse should instruct the client to consume at least 2.5 cups of fruits and vegetables per day.
  2. A nurse is providing discharge teaching about nutrition management to a client who has COPD. Which of the following instructions should the nurse include in the teaching? - Have a high-calorie protein drink between meals - Rationale: The nurse should encourage a client who has COPD to drink a high- calorie protein drink between meals. Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain
  3. A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of the following pain scales should the nurse use to assess the toddler's pain level? - FLACC scale - Rationale: The nurse should use the FLACC scale to assess pain for a 2-year- old child. The FLACC scale assesses facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.
  4. A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plan to take? - Gradually lengthen the time between the client's scheduled voids. - Rationale: The nurse should gradually lengthen the time between scheduled voids when implementing bladder retraining. The client is encouraged and taught to suppress the urge to void between scheduled voids through the use of pelvic exercises, distraction, and abdominal breathing. When the client is successfully able to suppress the urge, the time between voids is slightly increased. This process of scheduled voiding promotes retraining of the bladder and decreases urge incontinence
  5. A nurse is developing a plan of care for a client who has urinary incontinence. Which of the following actions should the nurse include? - Apply a moisture barrier cream to the client's skin. - Rationale: The nurse should apply a moisture barrier cream to protect the client's skin from urine. Urine is acidic and can lead to maceration of the skin.
  6. A nurse is preparing a client for an elective vaginal hysterectomy when the client states, "My doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already signed that consent form." Which of the following responses should the nurse make? - "You have the right to refuse this and any other procedure, even after you have signed the consent form." - Rationale: The client has the right to refuse treatment, even after signing the informed consent document. The nurse should inform the client of that