ATI RN Fundamentals Proctored Exam

Page 1 of 476 ATI RN Fundamentals 1. a nurse in a clinical is caring for a middle age adult 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 responsesshould the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "beginning at age 60, you should have a colonoscopy." C. "you should have a decal occult blood test every year." D. "the recommendation is to have a sigmoidoscopy every 10 years." "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for screening is a fecal occult blood test annually. 2. a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the followingintervention should the nurse take first? A. suction the client's airway B. administer a bronchodilator C. increase the humidity in the client's room D. assist the client to an upright position assist the client to an upright position When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on thediaphragm from abdominal organs. 3. 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? A. gently shake the container of medication prior to administration B. transfer the medication to a medicine cup C. place the client in a semi-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication ismixed. 4. a nurse is planning care to improve self-feeding for a client who has visionloss. which of the following interventions should the nurse include in the plan of care? A. tell the client which food she should eat first B. provide small-handle utensils for the client C. thicken liquids on the client's tray Page 25 of 476 D) Increase the room's temperature. Elevate the head of the client's bed. This action promotes postural drainage and also allows maximal chest expansion, which makes it easier for the client to breathe and decreases noisyrespirations. 79. A nurse is caring for a client who has a terminal diagnosis and whose healthis declining. The client requests information about advance directives. Which of the following responses should the nurse make? A) "We can talk about advance directives, and I can also give you some brochures about them." B) "You should set up a time to talk with your provider about that." C) "Let's discuss how you are feeling today, and we'll save the planning forwhen you are feeling a little better." D) "Why do you want to discuss this without your partner here to plan thiswith you?" "We can talk about advance directives, and I can also give you some brochuresabout them." With this statement, the nurse offers to provide the information the client needs ina direct and simple way. 80. A nurse is assessing a client who reports increased pain following physicaltherapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A) "Is your pain constant or intermittent?" B) "What would you rate your pain on a scale of 0 to 10?" C) "Does the pain radiate?" D) "Is your pain sharp or dull?" "Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching,burning, electriclike, or shooting helps determine the quality of the pain. 81. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information isthe priority for the nurse to provide? A) Admitting diagnosis B) Breath sounds C) Body temperature D) Diagnostic test results Breath sounds Page 50 of 476 a. Postural hypotension b. Distended neck veins c. Dependent edema d. Bradycardia - would be TACHY since SNS system kicks in when detects low blood volume TACHYCARDIA is for fluid overload. Isnt wherever the water goes the sodium follows. The lady on ati gave me a remediation hw about manifestation of hypernatremia: hyperthermia, tachycardia, and orthostatic hypotension. Therefore it‟s opposite→ bradycardia. TBC by the group 40. A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely increase the client‟s motivation to learn? a. The nurse empathy about the client having to self-inject b. The client's belief that his needs will be met through education c. The client seeking family approval by agreeing to a teaching plan d. The nurse explaining the need for education to the client 41. A nurse is conducting a Weber test on a client. Which of the following is an appropriate action for the nurse to take? a. Deliver a series of high-pitched sounds at random intervals. b. Place an activated tuning fork in the middle of the client's forehead. c. Hold and activated tuning fork against the client's mastoid process. d. Whisper a series of words softly into one ear. 42. A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. a. “I need to check my medications for expiration dates.” b. “I will use the grab bars when getting in and out of the bathtub.” c. “I need to have a fire escape plan with my family.” d. “I need to set my hot water heater to 140 degrees Fahrenheit.”- no more than 120 degrees e. “I will apply tapes over frayed areas of electrical cord.” Page 75 of 476 a. Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate, percuss palpate) b. Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes) c. Place the diaphragm of the stethoscope over each quadrant d. Ask the client to cough upon auscultation (for lung assessment) 55. A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate? A. Evaluating healing of an incision B. Inserting a NG Tube C. Performing a simple dressing change. D. Changing IV tubing. 56. A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care? A. HR 105/min B. BMI 25 kg/m2 C. BP 148/92 D. Glucose 45mg/dl 57. A nurse is assessing a client‟s extraocular eye movements. Which of the following actions should the nurse take? A. Position the client 6.1m(20ft) away from the Snellen chart. B. Instruct the client to follow finger through the six cardinal position of gaze, C. Ask the client to cover her right eye during assessment of her left eye. D. Hold a finger 46cm (18inch) in front of the client‟s eye. 58.A nurse is planning care for a client who has prescription of knee-length antibolic stockings. Which of the following actions should the nurse take? Page 100 of 476 13. A nurse is providing discharge teaching to 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? a. Check the cord routinely for frays or tearing b. Consider purchasing a generator for power backup c. Observe for signs of hypoxia d. Clothing and bedding should not be made from synthetic fabric b/c it can generate static electricity, the client should wear cotton instead. Oxygen equipment should be at least 10 feet away from open flames (gas stove, fireplace). 14. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first? a. Check the IV tubing for obstruction 15. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? a. Evaluate electrolytes b. Assess the client’s electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances. You should not restrict intake of oral fluids first. 16. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? a. Insert the IV catheter w/o using a tourniquet. b. The nurse should use the tourniquet minimally or not at all to avoid injury to f \ragile skin or veins. 17. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? a. Second intercostal space at the left sternal border 18. A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? a. Elevate the head of the client's bed Page 125 of 476 b. Ambulating c. Toileting d. Determining pain level e. Measuring vital signs Chapter 3 1. 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 2. 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 3. A nurse is instructing a group of newly license 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 Page 150 of 476 d. Attempting to master a skill. 5. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? a. “I should keep feeding my son whole milk until he is 3 years old.” b. “It‟s okay for me to give my son a cup of apple juice with each meal.” c. “I‟ll give my son about 2 tablespoons of each food at mealtimes.” d. “My son loves popcorn, and I know it is better for him than sweets.” Chapter 20 1. A nurse is talking with the guardian of a 4-year-old child who reports that the child is waking up with nightmares. Which of the following interventions should the nurse suggest? a. Offer the child a large snack before bedtime. b. Allow the child to watch an extra 30 min of TV in the evening. c. Have the child go to bed at a consistent time every day. d. Increase physical activity before bedtime. 2. A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) a. Assembling puzzles. b. Pulling wheeled toys. c. Using musical toys. d. Playing with puppets. e. Coloring with crayons. Page 175 of 476 to attend my child‟s wedding.” Based on the Kubler-Ross model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance 3. A nurse is consoling the partner of a client who just died after a long battle liver cancer. The grieving partner states, “I hate them for leaving me.” Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) a. “Would you like to contact the chaplain to come and speak with you?” b. “You will feel better soon. You have been expecting for a while now.” c. “Let‟s talk about your children and how they are going to react.” d. “You know, it is quite normal to feel anger toward your loved one at this time.” e. “Tell me more about how are you feeling.” 4. A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client‟s family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? a. Regular breathing pattern. b. Warm extremities. c. Increased urine output. d. Decreased muscle tone. 5. A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) a. Remove the dentures from the body. b. Make sure the body is lying completely flat. Page 200 of 476 b. Test the urine with a urine reagent strip. c. Wrap the hand in a warm, moist cloth. d. Perform a venipuncture to obtain a venous sample. 4. A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) a. Perform SMBG once daily at bedtime. b. Wipe the hand with an alcohol swab. c. Hold the hand in a dependent position prior to the puncture. d. Place the puncturing device perpendicular to the site. e. Prick the outer edge of the fingertip for the blood sample Chapter 53 1. A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) a. Restlessness b. Tachypnea c. Bradycardia d. Confusion e. Hypertension 2. A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) a. Apply petroleum jelly around and inside the nares. b. Remove the nasal cannula during mealtimes. c. Check the position of the cannula frequently. d. Report any nausea or difficulty breathing. e. Post “No Smoking” signs in prominent locations. Page 225 of 476 Self-concept and -monitor anger,emotions sexuality: Providing -encourage client to participate client support in care following a -arrangesupport group orvisit mastectomy: from someone in similar situation -counseling -discuss alternative means of sexual expression (hugging, cuddling) -therapeutic communication Mobility & -do not alter crutches after fitting Immobility: -follow prescribed crutchgait Appropriate use of -support body weight at the hand crutches: grips w/the elbows flexed at 30 degrees -position crutches on the unaffected side when sitting or rising from a chair -keep crutches 6 inches to the frontand to the side of client when walking -don't let crutches fit under the armpit - allow some space to avoid damage to skin or nerves in axillae Urinary elimination: -keep skin dry and clean preventing skin -assess for signs of breakdown breakdown -apply protective barrier creams 15/29 Page 250 of 476 57. A nurse is caring for a group of clients. For which of the following situatuons should the nurse complete an incident report? (Select all that apply) 1) A client is unable to afford the physical therapy that the provider recommends 2) A client becomes disoriented and falls out of bed 3) A client reports being dissatisfied with the temperature of the meals provided 4) A client’s visitor becomes dizzy and faints in the client’s room 5) A client receives burns from a heating pad 58. A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take? a) Have the client sign an against medical advice form b) Tell the client that the surgeon will prescribe restraints if they try to leave c) Administer a sedative medication to the client d) Explain to client that they cannot leave until the surgeon discharges them 59. A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration? a) Speech b) Physical c) Occupational d) Respiratory 60. A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client’s health record? a) Client drank adequate amounts of fluid with meals b) Episiotomy approximated, 3 cm (1.18 in) in length c) Client instructed on self-care needs d) Oral temperature elevated at 0800 61. A nurse is in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate? a) sub q b) mcg c) qhs d) qod 62. A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy? a) “I will do my best to fulfill my promises to you” b) “I will keep your personal information private” c) “I will speak with your provider on your behalf” d) “I will let you make decisions about your health care” Page 275 of 476 15. SECURITY AND DISASTER PLANS A. Triage a. Class 1: Emergent category (red tag) 1. Highest priority- life threatening injuries b. Class 2: Urgent Category (Yellow tag) 1. Second highest priority- major injuries (ex: bone fracture) c. Class 3: Nonurgent Category (Green tag) 1. Minor injuries (ex: sprain, cut) d. Class 4: Expectant category (black tag) 1. Not expected to live and allowed to die naturally (ex: chest is crushed) B. Tornado a. Close drapes, lower bed to lowest position and move away from windows, place blanket over clients who are confined to bed C. Chemical Incident a. b. Undress the client Irrigate skin with running water 1. Except dry chemicals- then brush the agent off clothes and skin D. Hazardous material a. b. Identify hazardous material Use water E. Bomb threat a. b. 16. Extend conversation for as long as possible Listen for distinguishing background noises to help police HEALTH PROMOTION AND DISEASE PREVENTION A. Tests 19 Page 300 of 476 g. Slow the flow by lowering the container if the client reports cramping C. Ostomy Care a. b. c. Remove the pouch Inspect the stoma- should appear moist and pink, peristomal area should be intact Use mild soap and water to cleanse the skin and dry it gently and completely 1. NO MOISTURIZING SOAPS d. e. Cut the opening 0.15-0.3 cm (1/18 to 1/8 in) larger Fold the bottom of the pouch and clamp it D. Diarrhea a. Fluid and electrolyte disturbances: metabolic acidosis 1. Monitor for dehydration a. Weak/rapid pulse, hypotension, poor skin turgor, elevated body temperature b. 44. Skin breakdown around the anal area—zinc oxide URINARY ELIMINATION A. Input and Output a. b. Input should be about the same as the output Output less than 30 mL/hr for more than 2 hours is a cause for concern B. Timed Urine Specimens a. b. Collect for 24 hours Discard the first voiding and then collect all other urine 1. Refrigerate, label, and transport specimen C. Catheter Care a. 44 Use soap and water at the insertion site Page 325 of 476 FUNDAMENTALS EXAM 1) A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. Correct Answer: A 2) When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. Correct Answer: A 3) The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. Correct Answer: B Page 350 of 476 19) The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? A Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. B Develop a chart for the client, listing the times the medication should be taken. C Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. D Instruct the client and client's children to put medications in a weekly pill organizer Correct Answer: C 20) The LPN/LVN expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A Dyspnea B Flushed face C Precordial pain D Increased pulse rate E Increased blood pressure Correct Answer: B,D 21) The LPN/LVN should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: A Force urine to back up into the kidneys. B Suppress production of urine. C Cause the device to pull away from the skin. D Tear the ileal conduit Correct Answer: C 22) A LPN is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most Page 375 of 476 should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following. Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient. 35. Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit. Rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin. 36. A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds Page 400 of 476 of the following statement by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushes what I urinated at 7 am and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the txt quickly." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and saveall subsequent voidings. 12. a nurse is caring for a client who has herpes zoster and asks the runs aboutthe use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture Acupuncture The nurse should inform the client that the use of acupuncture is contraindicatedfor a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection. 13. a nurse is preparing to transfer a client who has right-sided weakness fromthe bed to a chair. in what order should the nurse take the following actionsto assist the client? 1. ask the client is he can bear weight 2. use the stand-pivot technique to move the client to the chair 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 1. ask the client is he can bear weight 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 2. use the stand-pivot technique to move the client to the chair 14. a nurse is preparing to administer an injection of an opioid medication to aclient. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take? A. ask another nurse to observe the medication wastage B. notify the pharmacy when eating the medication C. lock the remaining medication in the controlled substance cabinet Page 425 of 476 The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals120 mL of fluid. 96. A nurse is planning teaching for a group of adolescents who each recentlyhad surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A) Role play B) Group discussions C) Question-answer meetings D) Practice sessions Practice sessions Practice sessions require psychomotor skills when learning. 97. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurseinclude in the teaching? A) Remove the outer cannula cautiously for routine cleaning. B) Use tracheostomy covers when outdoors. C) Use sterile technique when performing tracheostomy care at home. D) Cleanse irritated skin with full-strength hydrogen peroxide. Use tracheostomy covers when outdoors. Tracheostomy covers protect the client's airway from cold air, dust, and otherairborne particles. 98. A nurse is educating a client who has a terminal illness about her request todecline resuscitation in her living will. The client asks what would happen ifshe arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? A) "We will determine who the durable power of attorney for health careform has designated." B) "We will apply oxygen through a tube in your nose." C) "We will ask if you have changed your mind." D) "We will insert a breathing tube while we evaluate your condition." "We will apply oxygen through a tube in your nose." Oxygen can provide comfort and is not resuscitative when the nurse delivers itvia nasal cannula. 99. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of thefollowing actions should the nurse include? Page 450 of 476 A. apply the stockings so the creases are on the front of the leg B. apply the stockings while the client's legs are in a dependent position C. remove the stockings at least once per shift D. remove the stockings while the client is sitting in a reclining chair Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client'scirculation and skin integrity. 43. 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 actionsshould the nurse take first? A. rinse the feeding bag with water between feedings B. tell the client to keep the head of the bed elevated at least 30º C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteralformula; therefore, the priority intervention is to keep the head of the bedelevated at least 30° to prevent reflux of the formula backward into the esophagus. 44. a nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene 45. a nurse is responding to a call light and finds a client lying on the bathroomfloor. which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. notify the provider D. ask the client to describe how she felt prior to the fall Check the client for injuries. The first action the nurse should take when using the nursing process is to assess Page 475 of 476 Droplet Droplet precautions are a requirement for clients who have infections that spreadvia droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 ft) of the client who has a disorder requiring droplet precautions. 57. A nurse is admitting a client who is having an exacerbation of heart failure.In planning this client's care, when should the nurse initiate discharge planning? A) During the admission process B) As soon as the client's condition is stable C) During the initial team conference D) After consulting with the client's family During the admission process Discharge planning should begin as soon as the client is undergoing admission. The nurse should begin to assess the client's needs and plan for care during andafter hospitalization. 58. A middle adult client tells the nurse, "I feel so useless now that my childrendo not need me anymore." Which of the following responses should the nurse make? A) "Most people are happy when their children grow up and leave home." B) "You should be proud that your children are becoming independent." C) "Maybe you should consider why you are feeling useless." D) "People in middle adulthood often find satisfaction in nurturing andguiding young people." "People in middle adulthood often find satisfaction in nurturing and guidingyoung people." According to Erik Erikson, the task of middle adulthood is generativity versus selfabsorption and stagnation. The focus of this task is on offering support andguidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people. 59. 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 overthe bedrail onto the floor. Which of the following statements should the nurse document about this incident? A) "Incident report completed." B) "Client climbed over the bedrails."