BOARDVITALS Fundamentals Review

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ATI: BOARD VITALS

34 terms m_c_e_1Preview ATI Exa 47 terms mkg The nurse is caring for a group of clients on a medical- surgical floor when a fire alarm begins to alarm and smoke is smelled on the unit. What is the most appropriate initial action by the nurse?

• move clients to a safe area
• call in an alert to local authorities
• close all doors where the smoke was first noted
• if a fire is noted, take a fire extinguisher and extinguish

the flames A Place the following types of restraints in order form the

least to the most restrictive devices:

Mittens 1-point soft restraint All 4 side rails Roll belt 4-point soft restraints

• side rails, roll belt, mittens, 1 point, 4 point

When a client becomes combative, what documentation is required for the nurse to use client restraints?

• order from the physician or provider within 1 hour of

the placement of restraints

• length of time for which alternative measures were

used to control behavior prior to restraint

• Seriousness of the injury inflicted on staff due to

client's behavior

• body mass index of the client perceived to pose a

threat A nurse is caring for a client who requires mitten restraints to keep them from pulling out a urinary catheter. What nursing documentation is needed each shift?

• continuous pulse oximetry
• type of skin care provided
• name of visitors
• age of client

B Which alternatives to restraints should the nurse consider for a client in a long-term care facility who has been confused at night and fallen?

• keep a bedside commode near the bed
• position the head of bed upright
• leave a night light on continuously
• pit socks on the client's feet

C A nurse is completing a pain assessment for a toddler and asks the toddler to self-report pain. Which of the following pain scales should the nurse use?

A. FACES

B. FLACC

• Numeric scale
• Children's hospital of Eastern Ohio Pain Scale

(CHEOPS)

A A nurse is teaching a group of clients about interventions to promote sleep. Which of the following interventions should the nurse include in the teaching?

• exercise moderately in the late afternoon
• limit naps to 20 mins twice per day
• Avoid eating cheese or drinking milk at bedtime
• Relax by watching television before bedtime

B

A nurse is caring for a client who is experiencing difficulty sleeping at night. Which of the following actions should the nurse take to assist the client with sleep?

• provide a high protein bedtime snack
• administer medications that promote sleep routinely

each night

• encourage the client to take walks in the hallway

during the day

• encourage the client to stay in bed until sleep occurs

C A nurse in an acute care facility is admitting a client who has dementia due to Alzheimers. The client's partner is the client's primary caregiver and reports that he has been feeling tired and neglecting his own basic physiologic needs. Which of the following interventions should the nurse include when discussing the client's plan of care? SOA

• insist that the partner place the client in a long-term

care facility

• suggest that the partner see a counselor to help him

cope with his exhaustion

• ask the partner to talk about his difficulties in caring for

the client

• suggest the partner call a family meeting to get help
• offer reassurance that things will start to get better

B, C, D

A nurse is making a home visit to a client who has dementia and whose family members act as caregivers.The nurse should include which of the following instructions when providing education to the family members?

• explain to the client that any delusions are false
• give the client several choices to promote autonomy

and independence

• keep the client awake and busy during the day to

promote sleep at night

• offer finger foods to the client at mealtimes

D A nurse is caring for a client with Lewy body dementia.The nurse understands that effective communication with a client with dementia can be facilitated by which of the following?

• speaking in a loud voice
• touching the client gently before beginning a

conversation

• using simple sentences
• using open ended questions

C

Which of the following should a nurse include in teaching about techniques to improve sleep for a client with insomnia? SOA

• take short naps in the afternoon
• increase in the bedroom temperature
• watch television quietly in bed to provide a distraction

from thoughts

• avoid vigorous exercise within 6 hours before bedtime
• use relaxation techniques to relieve stress that may be

the cause of insomnia D, E A nurse is caring for a client who is at risk of falls. Which of the following is the appropriate intervention to reduce the client's risk?

• remove side rails
• use PRN restraints
• keep the hospital bed in the low position
• dim the lighting in the evening

C A nurse is working in a long-term care facility when a fire breaks out. What is the nurse's priority?

• activate the fire alarm system
• extinguish the flames using an appropriate fir

extinguisher

• remove any clients from the area to rescue them from

immediate danger

• open the windows and doors to allow the smoke to

dissipate C A nurse is caring for a client with major depressive disorder who complains of insomnia. Which of the following interventions should the nurse suggest to address this problem? SOA

• vigorously exercise for 30 minutes just before bedtime
• spend time in a quiet activity just before bedtime
• avoid sunlight during the day
• take a warm bath just before bedtime
• take a nap in the late afternoon to compensate for lost

sleep B, D An 82 year old client is admitted with pyelonephritis and agitation. The client appears confused and is disoriented to place and time. Which of the following is the priority nursing intervention?

• providing a quiet environment with low lighting
• providing close one-on-one supervision
• encouraging the client to maintain adequate fluid

intake

• raising the side rails of the bed

B