A nurse is reviewing protocol in preparation for suctioning secretions from a client

ATI RN Fundamentals Online Practice 2019 B with NGN A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

• Client flow sheet
• Acuity ratings
• Current medications
• Incident reports - CORRECT ANSWER C. Current medications

The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

• Use a resuscitation bag with 80% oxygen prior to the procedure.
• Select a suction catheter that is half the size of the lumen. 1 / 4

• Place the end of the suction catheter in water-soluble lubricant.
• Adjust the wall suction apparatus to a pressure of 170 mm Hg. - CORRECT

ANSWER B. Select a suction catheter that is half the size of the lumen.The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

• Place a pillow under the client's knees.
• Position a trochanter roll under each of the client's hips.
• Advise the client to wear rubber-soled slippers.
• Apply an ankle-foot orthotic device to the client's feet. - CORRECT ANSWER
• Apply an ankle-foot orthotic device to the client's feet.

The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? 2 / 4

• A nurse who is caring for a client reviews the client's medical chart with a

nursing student who is working with the nurse.

• A nurse asks a nurse from another unit to assist with documentation for a

client.

• A nurse who is caring for a client returns a call to the person appointed in the

health care proxy to discuss the client's care.

• A nurse discusses a client's status with the physical therapist who is caring for

the client. - CORRECT ANSWER B. A nurse asks a nurse from another unit to assist with documentation for a client.Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.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?

• Gently shake the container of medication prior to administration.
• Transfer the medication to a medicine cup.
• Place the client in a semi-Fowler's position prior to medication administration.
• Verify the dosage by measuring the liquid before administering it. - CORRECT

ANSWER A. Gently shake the container of medication prior to administration.The nurse should gently shake the liquid medication to ensure that the medication is mixed. 3 / 4

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

• Seal unused medications from the facility in a plastic bag.
• Evaluate the client's ability to self-administer medications.
• Report an identified discrepancy to The Joint Commission.
• Compare prescriptions with medications the client received while at the

facility. - CORRECT ANSWER D. Compare prescriptions with medications the client received while at the facility.When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

• "What could I have done to deserve this illness?"
• "I blame medical science for not curing me."
• "Where is my daughter at a time like this?"
• "Will I ever begin to feel in charge of my life again?" - CORRECT ANSWER
• "What could I have done to deserve this illness?"

The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

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