ATI Fundamentals Final Exam

a nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? a) establish client outcomes b) collect informati ...

a nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? a) establish client outcomes b) collect information about past health problems c) determine whether the client has met specific goals d) identify the client's specific health problem a) establish client outcomes The planning phase includes developing goals and outcomes that help the nurse create the client's plan of care. The nursing process: step 1. assessment phase- collect information about past health problems (vitals, age, height) step 2. analysis phase- identify the client's specific health problem step 3. planning phase- establish client goals and outcomes and selects interventions that will help to achieve them. Also involves setting care priorities. step 4. implementation- provides client care and uses interpersonal/technical skills when implementing nursing interventions step 5. evaluation phase- use critical thinking skills to determine whether the client has met a specific goal. examines results, compares the data, identifies errors, and considers pt's situation a client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? a) encourage the client to take deep breaths b) observe the client's rate, depth, and character of respirations c) prepare to administer oxygen d) give the client a backrub to promote relaxation b) observe the client's rate, depth, and character of respirations a nurse is collecting health history data from a client who is deaf and uses American sign language(ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? a) face away from the client to avoid distractions b) pace speech to allow time for the interpreter to convey the words c) make eye contact with the interpreter when explaining the procedure d) stand in the background while the interpreter translates the message b) pace speech to allow time for the interpreter to convey the words a nurse manager is providing teaching to a group of newly licensed nurses about the ways that clients acquire healthcare-associated-infections (HAI's). Which of the following routes of infection should the manager identify as an iatrogenic HAI? a) infection required from improper hand hygiene b) infection acquired by drug resistance c) infection acquired by inappropriate waste disposal d) infection acquired from diagnostic procedure d) infection acquired from diagnostic procedure Iatrogenic HAIs directly result from diagnostic or therapeutic procedures a nurse is caring for a client who has Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? a) wear gloves when changing the clients gown b) use alcohol-based sanitizers to cleanse the hands c) wear a mask when assisting the client with his meal tray d) place the client on a complete bed rest a) wear gloves when changing the clients gown -alcohol-based sanitizers are ineffective against the spores of C.difficile -nurse should wear a mask when working within 3 ft of a patient with droplet precautions -the nurse should not place the client on complete bed rest because this places him at risk for the hazards of immobility, such as impaired skin integrity and retained respiratory secretions. The nurse should instruct the patient to stay in his room but to move, cough, and deep breathe at least every 2 hours